N.Y. ISC Law § 3216 — New York Code / Act ISC / Article 32 / Section 3216
Individual accident and health insurance policy provisions
Status: in_force

§ 3216. Individual accident and health insurance policy provisions.\n(a) In this section the term:\n  (1) "Policy of accident and health insurance" includes any individual\npolicy or contract covering the kind or kinds of insurance described in\nparagraph three of subsection (a) of section one thousand one hundred\nthirteen of this chapter.\n  (2) "Indemnity" means benefits promised.\n  (3) "Family" may include the policyholder's spouse, or dependent\nchildren, or any other person dependent upon the policyholder.\n  (4) "Dependent children" (A) shall include any children under a\nspecified age which shall not exceed age nineteen except:\n  (i) Any unmarried dependent child, regardless of age, who is incapable\nof self-sustaining employment by reason of mental illness, or\ndevelopmental disability as defined in the mental hygiene law, or\nphysical handicap and who became so incapable prior to the age at which\ndependent coverage would otherwise terminate, shall be included in\ncoverage subject to any pre-existing conditions limitation applicable to\nother dependents; or\n  (ii) Any unmarried student at an accredited institution of learning\nmay be considered a dependent child until attaining age twenty-three for\na policy other than hospital, medical, surgical, or prescription drug\nexpense insurance; or\n  (iii) Any married or unmarried child shall be considered a dependent\nchild until attaining age twenty-six without regard to financial\ndependence, residency with the policyholder, student status, or\nemployment, for a policy of hospital, medical, surgical, or prescription\ndrug expense insurance.\n  (B) may include, at the option of the insurer, any unmarried child\nuntil attaining age twenty-five for a policy other than hospital,\nmedical, surgical, or prescription drug expense insurance.\n  (C) In addition to the requirements of subparagraphs (A) and (B) of\nthis paragraph, every insurer issuing a policy of hospital, medical, or\nsurgical expense insurance pursuant to this section that provides\ncoverage for dependent children must make available and, if requested by\nthe policyholder, extend coverage under the policy to an unmarried child\nthrough age twenty-nine, without regard to financial dependence who is\nnot insured by or eligible for coverage under an employer health benefit\nplan as an employee or member, whether insured or self-insured, and who\nlives, works or resides in New York state or the service area of the\ninsurer. Such coverage shall be made available at the inception of all\nnew policies. Written notice of the availability of such coverage shall\nbe delivered to the policyholder thirty days prior to the inception of\nsuch policy.\n  (b) No policy of accident and health insurance, including\nnon-cancellable disability insurance, except as provided in subsection\n(h) hereof, shall be delivered or issued for delivery in this state\nuntil the rate manual showing rates, rules and classifications of risks\nfor use in connection with such accident and health insurance policies\nor with riders or endorsements thereon, has been filed with the\nsuperintendent.\n  (c) No policy of accident and health insurance shall be delivered or\nissued for delivery to any person in this state unless:\n  (1) The entire money and other considerations therefor are expressed\ntherein.\n  (2) The time at which the insurance takes effect and terminates is\nexpressed therein.\n  (3) It purports to insure only one person, except that a policy may\ninsure, originally or by subsequent amendment, members of a family, as\ndefined herein, upon the application of an adult member of the family\nwho shall be deemed the policyholder.\n  (4) (A) Coverage of an unmarried dependent child who is incapable of\nself-sustaining employment by reason of mental illness, developmental\ndisability, as defined in the mental hygiene law, or physical handicap\nand who became so incapable prior to attainment of the age at which\ndependent coverage would otherwise terminate and who is chiefly\ndependent upon such policyholder for support and maintenance, shall not\nterminate while the policy remains in force and the dependent remains in\nsuch condition, if the policyholder has within thirty-one days of such\ndependent's attainment of the limiting age submitted proof of such\ndependent's incapacity as described herein.\n  (B) Coverage of a dependent spouse or named insured which would\nterminate upon such spouse or named insured attaining the age prescribed\nin subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§\n1395 et seq. ("medicare"), as the age of first eligibility for the\nbenefits provided by such law shall not so terminate, if such dependent\nspouse is not then eligible for all of such benefits, for as long as the\npolicy remains in force and such dependent spouse remains ineligible to\nreceive any of such "medicare" benefits, provided proof of such\nineligibility is submitted to the insurer within thirty-one days of the\ndate notice of termination of coverage be sent by first class mail by\nthe insurer to the last known address of the policyholder.\n  (C) Any family coverage shall provide that coverage of newborn\ninfants, including newly born infants adopted by the insured or\nsubscriber if such insured or subscriber takes physical custody of the\ninfant upon such infant's release from the hospital and files a petition\npursuant to section one hundred fifteen-c of the domestic relations law\nwithin thirty days of birth; and provided further that no notice of\nrevocation to the adoption has been filed pursuant to section one\nhundred fifteen-b of the domestic relations law and consent to the\nadoption has not been revoked, shall be effective from the moment of\nbirth for injury or sickness including the necessary care and treatment\nof medically diagnosed congenital defects and birth abnormalities\nincluding premature birth, except that in cases of adoption, coverage of\nthe initial hospital stay shall not be required where a birth parent has\ninsurance coverage available for the infant's care. In the case of\nindividual coverage the insurer must also permit the person to whom the\npolicy is issued to elect such coverage of newborn infants from the\nmoment of birth. If notification and/or payment of an additional premium\nor contribution is required to make coverage effective for a newborn\ninfant, the coverage may provide that such notice and/or payment be made\nwithin no less than thirty days of the day of birth to make coverage\neffective from the moment of birth. This election shall not be required\nin the case of student insurance.\n  (5) (A) Any family policy providing hospital or surgical expense\ninsurance (but not including such insurance against accidental injury\nonly) shall provide that, in the event such insurance on any person,\nother than the policyholder, is terminated because the person is no\nlonger within the definition of the family as set forth in the policy\nbut before such person has attained the limiting age, if any, for\ncoverage of adults specified in the policy, such person shall be\nentitled to have issued to that person by the insurer, without evidence\nof insurability, upon application therefor and payment of the first\npremium, within sixty days after such insurance shall have terminated,\nan individual conversion policy that contains the essential health\nbenefits package described in paragraph three of subsection (f) of\nsection three thousand two hundred seventeen-i of this article. The\ninsurer shall offer one policy at each level of coverage as defined in\nsubsection (b) of section three thousand two hundred seventeen-i of this\narticle. The individual may choose any such policy offered by the\ninsurer. Provided, however, the superintendent may, after giving due\nconsideration to the public interest, approve a request made by an\ninsurer for the insurer to satisfy the requirements of this subparagraph\nthrough the offering of policies that comply with this subparagraph by\nanother insurer, corporation or health maintenance organization within\nthe insurer's holding company system, as defined in article fifteen of\nthis chapter.  The conversion privilege afforded herein shall also be\navailable upon the divorce or annulment of the marriage of the\npolicyholder to the former spouse of such policyholder.\n  (B) Written notice of entitlement to a conversion policy shall be\ngiven by the insurer to the policyholder at least fifteen and not more\nthan sixty days prior to the termination of coverage due to the initial\nlimiting age of the covered dependent. Such notice shall include an\nexplanation of the rights of the dependent with respect to the dependent\nbeing enrolled in an accredited institution of learning or his or her\nincapacity for self-sustaining employment by reason of mental illness,\ndevelopmental disability as defined in the mental hygiene law or\nphysical handicap.\n  (C) Such individual conversion policy shall be subject to the\nfollowing terms and conditions:\n  (i) The premium shall be that applicable to the form and amount of\ninsurance therefor.\n  (ii) The benefits provided under such policy shall become effective\nupon the date that such person was no longer eligible under the family\npolicy.\n  (iii) No insurer shall be required to issue a conversion policy if it\nappears that the person applying for such policy shall have at that time\nin force another insurance policy or hospital service or medical expense\nindemnity contract providing similar benefits or is covered by or is\neligible for coverage by a group insurance policy or contract providing\nsimilar benefits or shall be covered by similar benefits required by any\nstatute or provided by any welfare plan or program, which together with\nthe conversion policy would result in over insurance or duplication of\nbenefits according to standards on file with the superintendent relating\nto individual policies.\n  (6) The style, arrangement and overall appearance of the policy give\nno undue prominence to any portion of the text, and unless every printed\nportion of the text of the policy and of any endorsements or attached\npapers is plainly printed in light-faced type of a style in general use,\nthe size of which shall be uniform and not less than ten-point with a\nlower-case unspaced alphabet length not less than one hundred\ntwenty-point (the "text" shall include all printed matter except the\nname and address of the insurer, name or title of the policy, the brief\ndescription, if any, and captions and subcaptions).\n  (7) The exceptions and reductions of indemnity are set forth in the\npolicy and, except those which are set forth in subsection (d) of this\nsection, are printed, at the insurer's option, either included with the\nbenefit provision to which they apply, or under an appropriate caption\nsuch as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided that if\nan exception or reduction specifically applies only to a particular\nbenefit of the policy, a statement of such exception or reduction shall\nbe included with the benefit provision to which it applies.\n  (8) Each such form, including riders and endorsements, shall be\nidentified by a form number in the lower left-hand corner of the first\npage thereof.\n  (9) It contains no provision purporting to make any portion of the\ncharter, rules, constitution, or by-laws of the insurer a part of the\npolicy unless such portion is set forth in full in the policy, except in\nthe case of the incorporation of, or reference to, a statement of rates\nor classification of risks, or short-rate table filed with the\nsuperintendent.\n  (10) There is prominently printed on the first page thereof or there\nis attached thereto a notice to the effect that during a specified\nperiod of time, which shall not be less than ten days nor more than\ntwenty days from the date the policy is delivered to the policyholder,\nit may be surrendered to the insurer together with a written request for\ncancellation of the policy and in such event the insurer will refund any\npremium paid therefor including any policy fees or other charges,\nprovided, however, that this paragraph shall not apply to single premium\nnonrenewable policies insuring against accidents only or accidental\nbodily injuries only; provided, however, that a contract or certificate\nsold by mail order and a contract or certificate providing medicare\nsupplemental insurance or long-term care insurance must contain a\nprovision permitting the contract or certificate holder a thirty day\nperiod for such surrender.\n  (11) The age limit or date or period, if any, after which the coverage\nprovided by the policy will not be effective or the age limit, date or\nperiod after which the policy may not be renewed is stated in a renewal\nprovision set forth on the first page of the policy or as a separate\nprovision bearing an appropriate caption on the first page of the policy\nor in a brief description in not less than fourteen-point bold face type\nset forth on the first page of the policy. Nothing herein contained\nshall limit or restrict the right of the insurer to continue the policy\nafter the age or period so stated.\n  (12) Any policy, other than one issued in fulfillment of the\ncontinuing care responsibilities of an operator of a continuing care\nretirement community in accordance with article forty-six of the public\nhealth 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 DOES NOT MEET THE REQUIREMENTS OF A CONTINUING\nCARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY\nA RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."\n  (13) Any persons covered by the policy who are also members of a\nreserve component of the armed forces of the United States, including\nthe National Guard, shall be entitled, upon written request, to have\ntheir coverage suspended during a period of active duty as described\nherein.  The policy shall provide that the insurer will refund any\nunearned premiums for the period of such suspension. Persons covered by\nthe policy shall be entitled to resumption of coverage, upon written\napplication and payment of the required premium within sixty days after\nthe date of termination of the period of active duty, 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. Coverage\nshall be retroactive to the date of termination of the period of active\nduty. Such right of resumption provided for herein shall be in addition\nto other existing rights granted pursuant to state and federal laws and\nregulations and shall not be deemed to qualify or limit such rights in\nany way. No exclusion or waiting period may be imposed in connection\nwith coverage of a health or physical condition of a person entitled to\nsuch right of resumption, or a health or physical condition of any other\nperson 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  (14) To be entitled to the right defined in paragraph thirteen of this\nsubsection a person must be a member of a component of the armed forces\nof 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  (15) 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,\nexcept forms issued by the NY State of Health, the official Health Plan\nMarketplace, other than those specifically referenced in subparagraph\n(iv) of paragraph (a) of subdivision five of section forty-three hundred\nten and paragraph (v) of subdivision one of section two hundred six of\nthe public health law, required of an insured or applicant for insurance\nso that the insured or applicant shall register or decline registration\nin the donate life registry for organ, eye and tissue donations under\nthis section of the enrollment or renewal form and that the following is\nstated on the 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  (d) Each policy of accident and health insurance delivered or issued\nfor delivery to any person in this state shall contain the provisions\nspecified herein in the words in which the same appear in this\nsubsection, except that the insurer may, at its option, substitute for\none or more of such provisions corresponding provisions of different\nwording approved by the superintendent which are not less favorable in\nany respect to the insured or the beneficiary. Each provision contained\nin the policy shall be preceded by the applicable caption herein or, at\nthe insurer's option, by such appropriate captions or subcaptions as the\nsuperintendent may approve.\n  (1) Each policy shall, except with respect to designation by numbers\nor letters as used below, contain the following provisions:\n  (A) ENTIRE CONTRACT; CHANGES: This policy, including the endorsements\nand the attached papers, if any, constitutes the entire contract of\ninsurance. No change in this policy shall be valid until approved by an\nexecutive officer of the insurer and unless such approval be endorsed\nhereon or attached hereto. No agent or broker has authority to change\nthis policy or to waive any of its provisions.\n  (B) TIME LIMIT ON CERTAIN DEFENSES:\n  (i) After two years from the date of issue of this policy no\nmisstatements, except fraudulent misstatements, made by the applicant in\nthe application for such policy shall be used to void the policy or to\ndeny a claim for loss incurred or disability (as defined in the policy)\ncommencing after the expiration of such two year period.\n  (The foregoing policy provision shall not be so construed as to affect\nany legal requirement for avoidance of a policy or denial of a claim\nduring such initial two year period, nor to limit the application of\nsubparagraphs (A) through (E), inclusive, of this paragraph in the event\nof misstatement with respect to age or occupation or other insurance.)\n  (A policy which the insured has the right to continue in force subject\nto its terms by the timely payment of premium until at least age fifty\nor, in the case of a policy issued after age forty-four, for at least\nfive years from its date of issue, may contain in lieu of the foregoing\nthe following provision (from which the clause in parentheses may be\nomitted at the insurer's option) under the caption "INCONTESTABLE":\n  After this policy has been in force for a period of two years during\nthe lifetime of the insured (excluding any period during which the\ninsured is disabled), it shall become incontestable as to the statements\ncontained in the application.)\n  (ii) No claim for loss incurred or disability (as defined in the\npolicy) commencing after two years from the date of issue of this policy\nshall be reduced or denied on the ground that a disease or physical\ncondition not excluded from coverage by name or specific description\neffective on the date of loss had existed prior to the effective date of\ncoverage of this policy.\n  (C) GRACE PERIOD: A grace period of ........................ (insert a\nnumber not less than "7" for weekly premium policies, "10" for monthly\npremium policies and "31" for all other policies) days will be granted\nfor the payment of each premium falling due after the first premium,\nduring which grace period the policy shall continue in force.\n  (A policy in which the insurer reserves the right to refuse renewal\nshall have, at the beginning of the above provision, the following\nclause:\n  "Unless not less than thirty days prior to the renewal date the\ninsurer has delivered to the insured or has sent by first class mail to\nhis last address as shown by the records of the insurer written notice\nof its intention not to renew this policy beyond the period for which\nthe premium has been accepted,"\n  Furthermore, such a policy, except an accident only policy, shall also\nprovide in substance, in a provision thereof, or in an endorsement\nthereon or in a rider attached thereto, that the insurer may refuse\nrenewal of the policy only as of the renewal date occurring on, or\nnearest its first anniversary, or as of an anniversary of such renewal\ndate, or at the option of the insurer as of the renewal date occurring\non or nearest the anniversary of its date of last reinstatement.)\n  (D) REINSTATEMENT: If any renewal premium be not paid within the time\ngranted the insured for payment, a subsequent acceptance of the premium\nby the insurer or by any agent or broker duly authorized by the insurer\nto accept such premium, without requiring in connection therewith an\napplication for reinstatement, shall reinstate the policy; provided,\nhowever, that if the insurer or such agent or broker requires an\napplication for reinstatement and issues a conditional receipt for the\npremium tendered, the policy will be reinstated upon approval of such\napplication by the insurer or, lacking such approval, upon the\nforty-fifth day following the date of such conditional receipt unless\nthe insurer has previously notified the insured in writing of its\ndisapproval of such application. The reinstated policy shall cover only\nloss resulting from such accidental injury as may be sustained after the\ndate of reinstatement and loss due to such sickness as may begin more\nthan ten days after such date. In all other respects the insured and\ninsurer shall have the same rights thereunder as they had under the\npolicy immediately before the due date of the defaulted premium, subject\nto any provisions endorsed hereon or attached hereto in connection with\nthe reinstatement. Any premium accepted in connection with a\nreinstatement shall be applied to a period for which premium has not\nbeen previously paid, but not to any period more than sixty days prior\nto the date of reinstatement.\n  (The last sentence of the above provision may be omitted from any\npolicy which the insured has the right to continue in force subject to\nits terms by the timely payment of premiums until at least age fifty or,\nin the case of a policy issued after age forty-four, for at least five\nyears from its date of issue.)\n  (E) NOTICE OF CLAIM: Written notice of claim must be given to the\ninsurer within twenty days after the occurrence or commencement of any\nloss covered by the policy, or as soon thereafter as is reasonably\npossible. Notice given by or on behalf of the insured or the beneficiary\nto the insurer at -------------- (insert the location of such office as\nthe insurer may designate for the purpose), or to any authorized agent\nof the insurer or to any authorized broker, with information sufficient\nto identify the insured, shall be deemed notice to the insurer. (In a\npolicy providing a loss-of-time benefit which may be payable for at\nleast two years, an insurer may at its option insert the following\nbetween the first and second sentences of the above provision: Subject\nto the qualifications set forth below, if the insured suffers loss of\ntime on account of disability for which indemnity may be payable for at\nleast two years, he shall, at least once in every six months after\nhaving given notice of claim, give to the insurer notice of continuance\nof said disability, except in the event of legal incapacity. The period\nof six months following any filing of proof by the insured or any\npayment by the insurer on account of such claim or any denial of\nliability in whole or in part by the insurer shall be excluded in\napplying this provision. Delay in the giving of such notice shall not\nimpair the insured's right to any indemnity which would otherwise have\naccrued during the period of six months preceding the date on which such\nnotice is actually given.)\n  (F) CLAIM FORMS: The insurer, upon receipt of a notice of claim, will\nfurnish to the claimant such forms as are usually furnished by it for\nfiling proofs of loss. If such forms are not furnished within fifteen\ndays after the giving of such notice the claimant shall be deemed to\nhave complied with the requirements of this policy as to proof of loss\nupon submitting, within the time fixed in the policy for filing proofs\nof loss, written proof covering the occurrence, the character and extent\nof the loss for which claim is made.\n  (G) PROOFS OF LOSS: Written proof of loss must be furnished to the\ninsurer at its said office in case of claim for loss for which this\npolicy provides any periodic payment contingent upon continuing loss\nwithin ninety days after the termination of the period for which the\ninsurer is liable and in case of claim for any other loss within one\nhundred twenty days after the date of such loss. Failure to furnish such\nproof within the time required shall not invalidate nor reduce any claim\nif it was not reasonably possible to give proof within such time,\nprovided such proof is furnished as soon as reasonably possible and in\nno event, except in the absence of legal capacity, later than one year\nfrom the time proof is otherwise required.\n  (H) TIME OF PAYMENT OF CLAIMS: Indemnities payable under this policy\nfor any loss other than loss for which this policy provides any periodic\npayment will be paid immediately upon receipt of due written proof of\nsuch loss. Subject to due written proof of loss, all accrued indemnities\nfor loss for which this policy provides periodic payment will be\npaid ------------ (insert period for payment which must not be less\nfrequently than monthly) and any balance remaining unpaid upon the\ntermination of liability will be paid immediately upon receipt of due\nwritten proof.\n  (I) PAYMENT OF CLAIMS: Any indemnity for loss of life will be payable\nin accordance with the beneficiary designation and the provisions\nrespecting such payment which may be prescribed herein and effective at\nthe time of payment. If no such designation or provision is then\neffective, such indemnity shall be payable to the estate of the insured.\nAny other accrued indemnities unpaid at the insured's death may, at the\noption of the insurer, be paid either to such beneficiary or to such\nestate. All other indemnities will be payable to the insured.  (The\nfollowing provisions, or either of them, may be included with the\nforegoing provision at the option of the insurer: If any indemnity of\nthis policy shall be payable to the estate of the insured, or to an\ninsured or beneficiary who is a minor or otherwise not competent to give\na valid release, the insurer may pay such indemnity, up to an amount not\nexceeding $-------------- (insert an amount which shall not exceed one\nthousand dollars), to any relative by blood or connection by marriage of\nthe insured or beneficiary who is deemed by the insurer to be equitably\nentitled thereto. Any payment made by the insurer in good faith pursuant\nto this provision shall fully discharge the insurer to the extent of\nsuch payment.\n  Subject to any written direction of the insured in the application or\notherwise all or a portion of any indemnities provided by this policy on\naccount of hospital, nursing, medical, or surgical services may, at the\ninsurer's option and unless the insured requests otherwise in writing\nnot later than the time of filing proofs of such loss, be paid directly\nto the hospital or person rendering such services; but it is not\nrequired that the service be rendered by a particular hospital or\nperson.)\n  (J) PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense\nshall have the right and opportunity to examine the person of the\ninsured when and as often as it may reasonably require during the\npendency of a claim hereunder and to make an autopsy in case of death\nwhere it is not forbidden by law.\n  (K) LEGAL ACTIONS: No action at law or in equity shall be brought to\nrecover on this policy prior to the expiration of sixty days after\nwritten proof of loss has been furnished in accordance with the\nrequirements of this policy. No such action shall be brought after the\nexpiration of three years after the time written proof of loss is\nrequired to be furnished.\n  (L) CHANGE OF BENEFICIARY: Unless the insured makes an irrevocable\ndesignation of beneficiary, the right to change of beneficiary is\nreserved to the insured and the consent of the beneficiary or\nbeneficiaries shall not be requisite to surrender or assignment of this\npolicy or to any change of beneficiary or beneficiaries, or to any other\nchanges in this policy.\n(The first clause of this provision, relating to the irrevocable\ndesignation of beneficiary, may be omitted at the insurer's option.)\n  (M) "CONVERSION PRIVILEGE" (under this caption) a provision which\nshall set forth in substance the conversion privileges and related\nprovisions required of certain policies by paragraph five of subsection\n(c) of this section.\n  (2) Other provisions. No such policy delivered or issued for delivery\nto any person in this state shall contain provisions respecting the\nmatters set forth below unless such provisions are in the words (not\nincluding the designation by number or letter) in which the same appear\nin this paragraph except that the insurer may, at its option, use in\nlieu of any such provision a corresponding provision of different\nwording approved by the superintendent which is not less favorable in\nany respect to the insured or the beneficiary. Any such provision\ncontained in the policy shall be preceded individually by the\nappropriate caption appearing herein or, at the option of the insurer,\nby such appropriate individual or group captions or subcaptions as the\nsuperintendent may approve.\n  (A) CHANGE OF OCCUPATION: If the insured be injured or contract\nsickness after having changed his occupation to one classified by the\ninsurer as more hazardous than that stated in this policy or while doing\nfor compensation anything pertaining to an occupation so classified, the\ninsurer will pay only such portion of the indemnities provided in this\npolicy as the premium paid would have purchased at the rates and within\nthe limits fixed by the insurer for such more hazardous occupation. If\nthe insured changes his occupation to one classified by the insurer as\nless hazardous than that stated in this policy, the insurer, upon\nreceipt of proof of such change of occupation, will reduce the premium\nrate accordingly, and will return the excess pro-rata unearned premium\nfrom the date of change of occupation or from the policy anniversary\ndate immediately preceding receipt of such proof, whichever is the more\nrecent. In applying this provision, the classification of occupational\nrisk and the premium rates shall be such as have been last filed by the\ninsurer prior to the occurrence of the loss for which the insurer is\nliable or prior to date of proof of change in occupation with the state\nofficial having supervision of insurance in the state where the insured\nresided at the time this policy was issued; but if such filing was not\nrequired, then the classification of occupational risk and the premium\nrates shall be those last made effective by the insurer in such state\nprior to the occurrence of the loss or prior to the date of proof of\nchange in occupation.\n  (B) MISSTATEMENT OF AGE: If the insured's age has been misstated, all\namounts payable under this policy shall be such as the premium paid\nwould have purchased at the correct age.\n  (C) OTHER INSURANCE IN THIS INSURER: If an accident or sickness or\naccident and health policy or policies previously issued by the insurer\nto the insured be in force concurrently herewith,\n  making the aggregate indemnity for ------------(insert type of\ncoverage or coverages) in excess of $-------------(insert maximum limit\nof indemnity or indemnities) the excess insurance shall be void and all\npremiums paid for such excess shall be returned to the insured or to his\nestate,\nor, in lieu thereof:\n  Insurance effective at any one time on the insured under a like policy\nor policies in this insurer is limited to the one such policy elected by\nthe insured, his beneficiary or his estate, as the case may be, and the\ninsurer will return all premiums paid for all other such policies.\n  (D) INSURANCE WITH OTHER INSURERS: If there be other valid coverage,\nnot with this insurer, providing benefits for the same loss on a\nprovision of service basis or on an expense incurred basis and of which\nthis insurer has not been given written notice prior to the occurrence\nor commencement of loss, the only liability under any expense incurred\ncoverage of this policy shall be for such proportion of the loss as the\namount which would otherwise have been payable hereunder plus the total\nof the like amounts under all such other valid coverages for the same\nloss of which this insurer had notice bears to the total like amounts\nunder all valid coverages for such loss, and for the return of such\nportion of the premiums paid as shall exceed the pro-rata portion for\nthe amount so determined. For the purpose of applying this provision\nwhen other coverage is on a provision of service basis, the "like\namount" of such other coverage shall be taken as the amount which the\nservices rendered would have cost in the absence of such coverage.\n  (If the foregoing policy provision is included in a policy which also\ncontains the next following policy provision there shall be added to the\ncaption of the foregoing provision the phrase "--- EXPENSE INCURRED\nBENEFITS". The insurer may, at its option, include in this provision a\ndefinition of "other valid coverage", approved as to form by the\nsuperintendent, which definition shall be limited in subject matter to\ncoverage provided by organizations subject to regulation by insurance\nlaw or by insurance authorities of this or any other state of the United\nStates or any province of Canada, and by hospital or medical service\norganizations, and to any other coverage the inclusion of which may be\napproved by the superintendent. In the absence of such definition such\nterm shall not include group insurance, automobile medical payments\ninsurance, or coverage provided by hospital or medical service\norganizations or by union welfare plans or employer or employee benefit\norganizations. For the purpose of applying the foregoing provision with\nrespect to any insured, any amount of benefit provided for such insured\npursuant to any compulsory benefit statute (including any workers'\ncompensation or employer's liability statute) whether provided by a\ngovernmental agency or otherwise shall in all cases be deemed to be\n"other valid coverage" of which the insurer has had notice. In applying\nthe foregoing policy provision no third party liability coverage shall\nbe included as "other valid coverage".)\n  (E) INSURANCE WITH OTHER INSURERS: If there be other valid coverage,\nnot with this insurer, providing benefits for the same loss on other\nthan an expense incurred basis and of which this insurer has not been\ngiven written notice prior to the occurrence or commencement of loss,\nthe only liability for such benefits under this policy shall be for such\nproportion of the indemnities otherwise provided hereunder for such loss\nas the like indemnities of which the insurer had notice (including the\nindemnities under this policy) bear to the total amount of all like\nindemnities for such loss, and for the return of such portion of the\npremium paid as shall exceed the pro-rata portion for the indemnities\nthus determined.\n  (If the foregoing policy provision is included in a policy which also\ncontains the next preceding policy provision there shall be added to the\ncaption of the foregoing provision the phrase "--- OTHER BENEFITS". The\ninsurer may, at its option, include in this provision a definition of\n"other valid coverage", approved as to form by the superintendent, which\ndefinition shall be limited in subject matter to coverage provided by\norganizations subject to regulation by insurance law or by insurance\nauthorities of this or any other state of the United States or any\nprovince of Canada, and to any other coverage the inclusion of which may\nbe approved by the superintendent. In the absence of such definition\nsuch term shall not include group insurance, or benefits provided by\nunion welfare plans or by employer or employee benefit organizations.\nFor the purpose of applying the foregoing policy provision with respect\nto any insured, any amount of benefit provided for such insured pursuant\nto any compulsory benefit statute (including any workers' compensation\nor employer's liability statute) whether provided by a governmental\nagency or otherwise shall in all cases be deemed to be "other valid\ncoverage" of which the insurer has had notice. In applying the foregoing\npolicy provision no third party liability coverage shall be included as\n"other valid coverage".)\n  (F) RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of\nloss of time benefits promised for the same loss under all valid loss of\ntime coverage upon the insured, whether payable on a weekly or monthly\nbasis, shall exceed the monthly earnings of the insured at the time\ndisability commenced or his average monthly earnings for the period of\ntwo years immediately preceding a disability for which claim is made,\nwhichever is the greater, the insurer will be liable for only such\nproportionate amount of such benefits under this policy as the amount of\nsuch monthly earnings or such average monthly earnings of the insured\nbears to the total amount of monthly benefits for the same loss under\nall such coverage upon the insured at the time such disability commences\nand for the return of such part of the premiums paid during such two\nyears as shall exceed the pro-rata amount of the premiums for the\nbenefits actually paid hereunder; but this shall not operate to reduce\nthe total monthly amount of benefits payable under all such coverage\nupon the insured below the sum of two hundred dollars or the sum of the\nmonthly benefits specified in such coverages, whichever is the lesser,\nnor shall it operate to reduce benefits other than those payable for\nloss of time.\n  (The foregoing policy provision may be inserted only in a policy which\nthe insured has the right to continue in force subject to its terms by\nthe timely payment of premiums until at least age fifty or, in the case\nof a policy issued after age forty-four, for at least five years from\nits date of issue. The insurer may, at its option, include in this\nprovision a definition of "valid loss of time coverage", approved as to\nform by the superintendent, which definition shall be limited in subject\nmatter to coverage provided by governmental agencies or by organizations\nsubject to regulation by the insurance law or by insurance authorities\nof this or any other state of the United States or any province of\nCanada, or to any other coverage the inclusion of which may be approved\nby the superintendent or any combination of such coverages. In the\nabsence of such definition such term shall not include any coverage\nprovided for such insured pursuant to any compulsory benefit statute\n(including any workers' compensation or employer's liability statute),\nor benefits provided by union welfare plans or by employer or employee\nbenefit organizations.)\n  (G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any\npremium then due and unpaid or covered by any note or written order may\nbe deducted therefrom.\n  (H) CANCELLATION: Within the first ninety days after the date of\nissue, the insurer may cancel this policy by written notice delivered to\nthe insured, or sent by first class mail to his last address as shown by\nthe records of the insurer, stating when, not less than ten days\nthereafter, such cancellation shall be effective. In the event of\ncancellation, the insurer will return promptly the pro-rata unearned\nportion of any premium paid. Cancellation shall be without prejudice to\nany claim originating prior to the effective date of cancellation.\n  (Nothing in this subsection shall be construed to prohibit an insurer\nfrom granting to the insured the right to cancel a policy at any time\nand to receive in such event a refund of the unearned portion of any\npremium paid, computed by the use of the short-rate table last filed\nwith the state official having supervision of insurance in the state\nwhere the insured resided when the policy was issued).\n  (I) CONFORMITY WITH STATE STATUTES: Any provision of this policy\nwhich, on its effective date, is in conflict with the statutes of the\nstate in which the insured resides on such date is hereby amended to\nconform to the minimum requirements of such statutes.\n  (J) ILLEGAL OCCUPATION: The insurer shall not be liable for any loss\nto which a contributing cause was the insured's commission of or attempt\nto commit a felony or to which a contributing cause was the insured's\nbeing engaged in an illegal occupation.\n  (K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any\nloss sustained or contracted in consequence of the insured's being\nintoxicated or under the influence of any narcotic unless administered\non the advice of a physician.\n  (3) If any provision of this subsection is in whole or in part\ninapplicable to or inconsistent with the coverage provided by a\nparticular form of policy the insurer, with the approval of the\nsuperintendent, shall omit from such policy any inapplicable provision\nor part of a provision, and shall modify any inconsistent provision or\npart of the provision in such manner as to make the provision as\ncontained in the policy consistent with the coverage provided by the\npolicy.\n  (4) The provisions which are the subject of paragraphs one and two of\nthis subsection, or any corresponding provisions which are used in lieu\nthereof in accordance with such paragraphs, shall be printed in the\nconsecutive order of the provisions in such paragraphs or, at the option\nof the insurer, any such provision may appear as a unit in any part of\nthe policy, with other provisions to which it may be logically related,\nprovided the resulting policy shall not be in whole or in part\nunintelligible, uncertain, ambiguous, abstruse, or likely to mislead a\nperson to whom the policy is offered, delivered or issued.\n  (5) The word "insured", as used in this section, shall not be\nconstrued as preventing a person other than the insured with a proper\ninsurable interest from making application for and owning a policy\ncovering the insured or from being entitled under such a policy to any\nindemnities, benefits and rights provided therein.\n  (6) The superintendent may make such reasonable rules and regulations\nconcerning the procedure for the filing or submission of policies\nsubject to this section as are necessary, proper or advisable to the\nadministration of this section. This provision shall not abridge any\nother authority granted the superintendent by law.\n  (e) The acknowledgment by any insurer of the receipt of notice given\nunder any policy covered by this section, or the furnishing of forms for\nfiling proofs of loss, or the acceptance of such proofs, or the\ninvestigation of any claim thereunder, shall not operate as a waiver of\nany of the rights of the insurer in defense of any claim arising under\nsuch policy.\n  (f) If any such policy contains a provision establishing, as an age\nlimit or otherwise, a date after which the coverage provided by the\npolicy will not be effective, and if such date falls within a period for\nwhich premium is accepted by the insurer or if the insurer accepts a\npremium after such date, the coverage provided by the policy will\ncontinue in force subject to any right of cancellation until the end of\nthe period for which premium has been accepted. In the event the age of\nthe insured has been misstated and if, according to the correct age of\nthe insured, the coverage provided by the policy would not have become\neffective, or would have ceased prior to the acceptance of such premium\nor premiums, then the liability of the insurer shall be limited to the\nrefund, upon request, of all premiums paid for the period not covered by\nthe policy.\n  (g)(1) No insurer shall refuse to renew a policy of hospital, surgical\nor medical expense insurance, an individual converted policy, or any\nother policy in which one-third or more of the total premium is\nallocable to hospital, surgical or medical expense benefits, or any\ncombination thereof (but not including insurance against accidental\ninjury only), except for one or more of the following reasons:\n  (A) nonpayment of premiums,\n  (B) fraud in applying for the policy or in applying for any benefits\nunder the policy or intentional misrepresentation of material fact under\nthe terms of the coverage,\n  (C) discontinuance of a class of policies in accordance with paragraph\ntwo of this subsection, except that no insurer or organization certified\npursuant to article forty-four of the public health law shall refuse to\nrenew the policies of insureds holding contracts which provide major\nmedical or similar comprehensive type coverage in effect prior to June\nfirst, two thousand one who are ineligible to purchase policies offered\npursuant to section four thousand three hundred twenty-one or four\nthousand three hundred twenty-two of this chapter due to the provisions\nof section 42 USC 1395ss in effect on January first, two thousand one,\nand who are eligible for Medicare benefits by reason of disability.\n  (i) Coverage shall be reinstated only for such insureds terminated on\nor after January first, two thousand one and such coverage shall be\nreinstated on a prospective basis only, irrespective of any pre-existing\nconditions.\n  (ii) In the event any such insured becomes eligible to purchase\npolicies offered pursuant to section four thousand three hundred\ntwenty-one or four thousand three hundred twenty-two of this chapter,\nthen such insured may be discontinued upon not less than five months\nprior written notice. In the event any such insured becomes eligible for\nMedicare by reason of age, then such insured may be terminated by not\nless than thirty days notice with prior written notice.\n  (iii) Within sixty days of this item taking effect, the insurer or\norganization shall notify the insured of the prospective reinstatement\nof coverage under this section. Within thirty days of receipt of such\nnotice, an insured shall notify the insurer or organization of his or\nher election for prospective coverage,\n  (D) discontinuance of all hospital, surgical and medical expense\ncoverage in the individual market in this state in accordance with\nparagraph three of this subsection,\n  (E) in the case of an insurer that offers coverage in the individual\nmarket through a network plan, termination of an individual who no\nlonger resides, lives or works in the service area (or in an area for\nwhich the insurer is authorized to do business) but only if such\ncoverage is terminated under this subparagraph uniformly without regard\nto any health status-related factor of covered individuals, and\n  (F) for 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  In no event shall any insurer refuse to renew any such policy because\nof the physical or mental condition or the health of any person covered\nthereunder. Furthermore, no insurer shall require as a condition for the\nrenewal of any such policy any rider, endorsement or other attachment\nwhich shall limit the nature or extent of the benefits provided\nthereunder. The superintendent may require every insurer to file with\nhim such documents, statistics or other information regarding the\nrefusal to renew permitted by this subsection as he may deem necessary\nfor the proper administration of this subsection.\n  (2) In any case in which an insurer decides to discontinue offering a\nclass of hospital, surgical or medical expense policies in the\nindividual health insurance market, coverage of the class of policies\nmay be discontinued by the insurer only if:\n  (A) the insurer gives at least ninety days prior written notice of\nsuch discontinuance to the superintendent;\n  (B) the insurer provides written notice of such discontinuance to each\ncovered individual at least ninety days prior to the date of\ndiscontinuance of such coverage;\n  (C) the insurer offers to each covered individual the option to\npurchase all other individual hospital, surgical and medical expense\ncoverage currently being offered by the insurer in the individual health\ninsurance market; and\n  (D) in exercising the option to discontinue coverage of a class of\npolicies and in offering the option of coverage under subparagraph (C)\nof this paragraph, the insurer acts uniformly without regard to claims\nexperience or to any health status-related factor of insured individuals\nor individuals who may become eligible for such coverage.\n  (E) The superintendent may, after giving due consideration to the\npublic interest, approve a request made by an insurer for the insurer to\nsatisfy the requirements of subparagraph (C) of this paragraph through\nthe offering of policies at each level of coverage as defined in\nsubsection (b) of section three thousand two hundred seventeen-i of this\narticle that contains the essential health benefits package described in\nparagraph three of subsection (e) of section three thousand two hundred\nseventeen-i of this article by another insurer, corporation or health\nmaintenance organization within the insurer's same holding company\nsystem, as defined in article fifteen of this chapter.\n  (3) In any case in which an insurer elects to discontinue offering all\nhospital, surgical and medical expense coverage in the individual market\nin this state, health insurance coverage may be discontinued by the\ninsurer only if:\n  (A) the insurer gives at least one hundred eighty days prior written\nnotice of such discontinuance to the superintendent;\n  (B) the insurer provides written notice of such discontinuance to each\ncovered individual at least one hundred eighty days prior to the date of\ntermination of such coverage;\n  (C) all hospital, surgical and medical expense coverage issued or\ndelivered for issuance in this state in the individual market is\ndiscontinued and coverage under such health insurance coverage in such\nmarket is not renewed; and\n  (D) in addition to the notice referred to in subparagraph (A) of this\nparagraph, the insurer must provide the superintendent with a written\nplan to minimize potential disruption in the marketplace occasioned by\nits withdrawal from the individual market.\n  (4) In the case of a discontinuance under paragraph three of this\nsubsection, the insurer may not provide for the issuance of any policy\nof hospital, surgical or medical expense insurance in the individual\nmarket in this state during the five year period beginning on the date\nof the discontinuance of the last health insurance coverage not so\nrenewed.\n  (5) At the time of coverage renewal, an insurer may modify the health\ninsurance coverage for a policy form offered to individuals in the\nindividual market so long as such modification is consistent with this\nchapter and effective on a uniform basis among all individuals with that\npolicy form.\n  (6) 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 with the insurer or another entity which has contracted with\nthe insurer.\n  (h) This section shall not apply to or affect:\n  (1) Any contract of non-cancellable disability insurance which is\ngoverned by or excepted from section three thousand two hundred fifteen\nof this article.\n  (2) Any policy or contract of reinsurance.\n  (3) Any policy of group or blanket insurance which is governed by\nsection three thousand two hundred twenty-one of this article except\nthat the provisions of subsection (b) hereof and paragraphs one through\nten of subsection (i) hereof and the provisions of subsection (j) hereof\nshall be applicable to a policy of group insurance authorized under\nsubparagraph (J) of paragraph one of subsection (c) of section four\nthousand two hundred thirty-five of this chapter.\n  (4) Any policy providing disability benefits pursuant to article nine\nof the workers' compensation law.\n  (5) Any policy of a co-operative life and accident insurance company\nexcept as was provided in section two hundred thirty-seven of the former\ninsurance law.\n  (6) Life insurance, endowment or annuity contracts, or contracts\nsupplemental thereto which contain only such provisions relating to\naccident and health insurance as provide additional benefits in case of\ndeath or dismemberment or loss of sight by accident, or as operate to\nsafeguard such contracts against lapse, or to give a special surrender\nvalue or special benefit or an annuity in the event that the insured or\nannuitant shall become totally and permanently disabled, as defined by\nthe contract or supplemental contract.\n  (i) Every person insured under a policy of accident and health\ninsurance delivered or issued for delivery in this state shall be\nentitled to the reimbursements and coverages specified below.\n  (1) If a policy provides for reimbursement for any optometric service\nwhich is within the lawful scope of practice of a licensed optometrist,\nthe insured shall be entitled to reimbursement for such service whether\nit is performed by a physician or licensed optometrist. Unless such\npolicy shall otherwise provide there shall be no reimbursement for\nophthalmic materials, lenses, spectacles, eyeglasses, or appurtenances\nthereto.\n  (2) If a policy provides for reimbursement for any podiatrical service\nwithin the lawful scope of practice of a licensed podiatrist, the\ninsured shall be entitled to reimbursement for such service whether it\nis performed by a physician or licensed podiatrist.\n  (3) If a policy provides for reimbursement for any dental service\nwithin the lawful scope of practice of a licensed dentist, the insured\nshall be entitled to reimbursement for such service whether it is\nperformed by a physician or a licensed dentist.\n  (4) If a policy provides for reimbursement for psychiatric or\npsychological services or for diagnosis and treatment of mental health\nconditions however defined in the policy, the insured shall be entitled\nto reimbursement for such services, diagnosis or treatment whether\nperformed by a physician, psychiatrist, a certified and registered\npsychologist, or a nurse practitioner when the services rendered are\nwithin the lawful scope of their practice.\n  (5) Every policy providing for reimbursement for laboratory tests or\nreimbursement for diagnostic X-ray services shall provide for\nreimbursement at the same percentage of reimbursement whether such tests\nor services are provided to the insured as an admitted patient in a\nhealth care facility or as an out-patient.\n  (6) Every policy which provides coverage for in-patient hospital care\nshall provide coverage for home care to residents in this state. Such\nhome care coverage shall be included at the inception of all new\npolicies and, with respect to all other policies, at any anniversary\ndate of the policy subject to evidence of insurability.\n  (A) 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.\nHome care shall be provided by an agency possessing a valid certificate\nof approval or license issued pursuant to article thirty-six of the\npublic health law and shall consist of one or more of the following:\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 title subchapter XVIII of the federal Social Security Act, 42\nU.S.C.  §§ 1395 et seq.\n  (B) Coverage may be subject to an annual deductible of not more than\nfifty 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. 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  (7) Every policy which provides coverage for in-patient hospital care\nshall also provide coverage for pre-admission tests performed in\nhospital out-patient facilities prior to scheduled surgery provided:\n  (A) the tests are ordered by a physician as a planned preliminary to\nadmission of the patient as an in-patient for surgery in the same\nhospital;\n  (B) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed;\n  (C) reservations for a hospital bed and for an operating room shall\nhave been made prior to the performance of the tests;\n  (D) the surgery actually takes place within seven days of such\npresurgical tests; and\n  (E) the patient is physically present at the hospital for the tests.\n  (8) Every policy which provides coverage for in-patient surgical care\nshall include coverage for a second surgical opinion by a qualified\nphysician on the need for surgery.\n  (9)(A) Every policy that provides coverage for inpatient hospital care\nshall also include coverage for services to treat an emergency condition\nin 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) For purposes of this paragraph, an "emergency condition" means a\nmedical or behavioral condition that manifests itself by acute symptoms\nof sufficient 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) For purposes of this paragraph, "emergency services" means, with\nrespect to an emergency condition: (i) a medical screening examination\nas required under section 1867 of the Social Security Act, 42 U.S.C. §\n1395dd, which is within the capability of the emergency department of a\nhospital, including ancillary services routinely available to the\nemergency department to evaluate such emergency medical condition; and\n(ii) within the capabilities of the staff and facilities available at\nthe hospital, such further medical examination and treatment as are\nrequired under section 1867 of the Social Security Act, 42 U.S.C. §\n1395dd, to stabilize the patient.\n  (E) For purposes of this paragraph, "to stabilize" means, with respect\nto an emergency condition, to provide such medical treatment of the\ncondition as may be necessary to assure, within reasonable medical\nprobability, that no material deterioration of the condition is likely\nto result from or occur during the transfer of the insured from a\nfacility or to deliver a newborn child (including the placenta).\n  (10) (A) (i) Every policy which provides hospital, surgical or medical\ncoverage shall provide coverage for maternity care, including hospital,\nsurgical or medical care to the same extent that hospital, surgical or\nmedical coverage is provided for illness or disease under the policy.\nSuch maternity care coverage, other than coverage for perinatal\ncomplications, shall include inpatient hospital coverage for mother and\nfor newborn for at least forty-eight hours after childbirth for any\ndelivery other than a caesarean section, and for at least ninety-six\nhours after a caesarean section. Such coverage for maternity care shall\ninclude the services of a midwife licensed pursuant to article one\nhundred forty of the education law, practicing consistent with section\nsixty-nine hundred fifty-one of the education law and affiliated or\npracticing in conjunction with a facility licensed pursuant to article\ntwenty-eight of the public health law, but no insurer shall be required\nto pay for duplicative routine services actually provided by both a\nlicensed 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  * (C) 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  (10-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  (11) (A) Every policy that provides coverage for hospital, surgical or\nmedical care shall provide the following coverage for mammography\nscreening 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; and\n  (iv) 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 policy that provides coverage for hospital, surgical or medical\ncare, except for a grandfathered health plan under subparagraph (E) of\nthis paragraph, shall provide coverage for the following mammography\nscreening services, and such coverage shall not be subject to annual\ndeductibles 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-c) (A) Every policy which provides medical, major medical, or\nsimilar comprehensive-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 policy which provides coverage for prescribed drugs\napproved by the food and drug administration of the United States\ngovernment for the treatment of certain types of cancer shall not\nexclude coverage of any such drug on the basis that such drug has been\nprescribed for the treatment of a type of cancer for which the drug has\nnot been approved by the food and drug administration. Provided,\nhowever, that such drug must be recognized for treatment of the specific\ntype of cancer for which the drug has been prescribed in one of the\nfollowing 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  (13) (A) Every policy which provides coverage for hospital care shall\nnot exclude coverage for hospital care for diagnosis and treatment of\ncorrectable medical conditions otherwise covered by the policy solely\nbecause the medical condition results in infertility.\n  (B) Every policy which provides coverage for surgical and medical care\nshall not exclude coverage for surgical and medical care for diagnosis\nand treatment of correctable medical conditions otherwise covered by the\npolicy solely because the medical condition results in infertility.\n  (C) Every policy that provides medical, major medical or similar\ncomprehensive-type coverage shall provide coverage for standard\nfertility preservation services when a medical treatment may directly or\nindirectly cause iatrogenic infertility to an insured. Coverage may be\nsubject to annual deductibles and coinsurance, including copayments, as\nmay be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy.\n  (i) For purposes of this subparagraph, "iatrogenic infertility" means\nan impairment of fertility by surgery, radiation, chemotherapy or other\nmedical treatment affecting reproductive organs or processes.\n  (ii) No insurer providing coverage under this paragraph shall\ndiscriminate based on an insured's expected length of life, present or\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  (13-a) 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 insured who elects to purchase prescription fertility\ndrugs through a network participating non-mail order retail pharmacy\nthat it does not impose on any insured who purchases prescription\nfertility drugs through a network participating mail order or other\nnon-retail pharmacy.\n  (14) If a policy provides for reimbursement for the services of\nlicensed health professionals who can bill for services, the insured\nshall be entitled to reimbursement for such service provided pursuant to\na clinical practice plan established pursuant to subdivision fourteen of\nsection two hundred six of the public health law.\n  (15) (A) Every policy that provides hospital, surgical or medical care\ncoverage or provides reimbursement for laboratory tests or reimbursement\nfor diagnostic X-ray services shall provide coverage for an annual\ncervical cytology screening for cervical cancer and its precursor states\nfor women aged eighteen 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 policy that provides hospital, surgical or medical care coverage,\nexcept for a grandfathered health plan under subparagraph (E) of this\nparagraph, shall provide coverage for the following cervical cytology\nscreening services, and such coverage shall not be subject to annual\ndeductibles 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) (A) Every policy which provides medical coverage that includes\ncoverage for physician services in a physician's office and every policy\nwhich provides major medical or similar comprehensive-type coverage\nshall include coverage for the following equipment and supplies for the\ntreatment of diabetes, if recommended or prescribed by a physician or\nother licensed health care provider legally authorized to prescribe\nunder title eight of the education law: blood glucose monitors and blood\nglucose monitors for the visually impaired, data management systems,\ntest strips for glucose monitors and visual reading and urine testing\nstrips, insulin, injection aids, cartridges for the visually impaired,\nsyringes, insulin pumps and appurtenances thereto, insulin infusion\ndevices, and oral agents for controlling blood sugar. In addition, the\ncommissioner of the department of health shall provide and periodically\nupdate by rule or regulation a list of additional diabetes equipment and\nrelated supplies such as are medically necessary for the treatment of\ndiabetes, for which there shall also be coverage. Such policies shall\nalso include coverage for diabetes self-management education to ensure\nthat persons with diabetes are educated as to the proper self-management\nand treatment of their diabetic condition, including information on\nproper diets. Such coverage for self-management education and education\nrelating to diet shall be limited to visits medically necessary upon the\ndiagnosis of diabetes, where a physician diagnoses a significant change\nin the patient's symptoms or conditions which necessitate changes in a\npatient's self-management, or where reeducation or refresher education\nis necessary. 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  (16) If a policy provides for reimbursement for speech-language\npathology or audiology service which is within the lawful scope of\npractice of a duly licensed speech-language pathologist or audiologist,\nan insured shall be entitled to reimbursement for such service whether\nthe said service is performed by a physician or duly licensed\nspeech-language pathologist or audiologist, provided however, that\nnothing contained herein shall be construed to impair any terms of such\npolicy which may require said service to be performed pursuant to a\nmedical order, or a similar or related service of a physician, in which\ncase coverage need not be provided for any tests, evaluations or\ndiagnoses if such tests, evaluations or diagnoses have already been\nprovided by or through a physician within twelve months of the referral\nor order from the physician. However, nothing herein shall be construed\nas preventing an insurer from covering more than one test or evaluation\nprovided by a speech-language pathologist or audiologist within a\ntwelve-month period where such test or evaluation is ordered by a\nphysician as medically necessary. Nor shall anything herein be construed\nas prohibiting the limitation of such services, where covered, to\nspecified settings other than offices, such as hospitals or to services\nprovided by such professionals as part of a home care agency's services.\n  (17) (A) Every policy that provides medical, major-medical or similar\ncomprehensive-type coverage shall provide coverage for the provision of\npreventive and primary care services.\n  (B) For the purposes of subparagraphs (A), (C) and (D) of this\nparagraph, preventive and primary care services means the following\nservices rendered to a covered child of an insured from the date of\nbirth through the attainment of nineteen years;\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 policy that provides hospital, surgical or medical care\ncoverage, except for a grandfathered health plan under subparagraph (F)\nof this paragraph, shall provide coverage for the following preventive\ncare and screenings for insureds, and such coverage shall not be subject\nto 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, 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  (v) all FDA-approved contraceptive drugs, devices, and other products,\nincluding all over-the-counter contraceptive drugs, devices, and\nproducts as prescribed or as otherwise authorized under state or federal\nlaw; 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; patient education and\ncounseling on contraception; and follow-up services related to the\ndrugs, devices, products, and procedures covered under this clause,\nincluding, but not limited to, management of side effects, counseling\nfor continued adherence, and device insertion and removal. Except as\notherwise authorized under this clause, a contract shall not impose any\nrestrictions or delays on the coverage required under this clause.\nHowever, 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 contract is not required to\ninclude all such therapeutic and pharmaceutical equivalent versions in\nits formulary, so long as at least one is included and covered without\ncost-sharing and in accordance with this clause. If the covered\ntherapeutic and pharmaceutical equivalent versions of a drug, device, or\nproduct are not available or are deemed medically inadvisable a contract\nshall provide coverage for an alternate therapeutic and pharmaceutical\nequivalent version of the contraceptive drug, device, or product without\ncost-sharing. (a) This coverage shall include emergency contraception\nwithout cost sharing when provided pursuant to a prescription, or order\nunder section sixty-eight hundred thirty-one of the education law or\nwhen lawfully provided over-the-counter. (b) If the attending health\ncare provider, in his or her reasonable professional judgment,\ndetermines that the use of a non-covered therapeutic or pharmaceutical\nequivalent of a drug, device, or product is warranted, the health care\nprovider's determination shall be final. The superintendent shall\npromulgate regulations establishing a process, including timeframes, for\nan insured, an insured's designee or an insured's health care provider\nto request coverage of a non-covered contraceptive drug, device, or\nproduct. Such regulations shall include a requirement that insurers use\nan exception form that shall meet criteria established by the\nsuperintendent. (c) This coverage must allow for the dispensing of up to\ntwelve months worth of a contraceptive at one time. (d) For the purposes\nof this clause, "over-the-counter contraceptive products" shall mean\nthose products provided for in comprehensive guidelines supported by the\nhealth resources and services administration as of January twenty-first,\ntwo thousand nineteen.\n  (F) 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  (18) (A) Every policy which provides coverage for inpatient hospital\ncare shall provide such coverage for such period as is determined by the\nattending physician in consultation with the patient to be medically\nappropriate for such covered person undergoing a lymph node dissection\nor a lumpectomy for the treatment of breast cancer or a mastectomy\ncovered by the policy. Such coverage may be subject to annual\ndeductibles and coinsurance 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  (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  (19) (A) Every policy which provides medical, major medical, or\nsimilar comprehensive-type coverage must provide coverage for a second\nmedical opinion by an appropriate specialist, including but not limited\nto a specialist affiliated with a specialty care center for the\ntreatment of cancer, in the event of a positive or negative diagnosis of\ncancer or a recurrence of cancer or a recommendation of a course of\ntreatment for cancer, 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 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; or\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.\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  (20) (A) Every policy which provides medical, major medical, or\nsimilar comprehensive-type coverage shall provide the following coverage\nfor breast 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 policy providing coverage as required by subparagraph (A)\nof this paragraph shall also provide coverage for the tattooing of the\nnipple-areolar complex pursuant to or as part of such reconstruction if\nsuch tattooing is performed by a licensed physician or other health care\npractitioner licensed, certified, or authorized pursuant to title eight\nof the education law and acting within their scope 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  * (21) 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 (21)'s\n  * (21)(A) Every policy which is a "managed care product" as defined in\nsubparagraph (D) of this paragraph that provides 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 than 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 (21)'s\n  (22) No policy shall exclude coverage of a health care service, as\ndefined in paragraph two of subsection (e) of section four thousand nine\nhundred of this chapter, rendered or proposed to be rendered to an\ninsured on the basis that such service is experimental or\ninvestigational, is rendered as part of a clinical trial as defined in\nsubsection (b-2) of section forty-nine hundred of this chapter, or a\nprescribed pharmaceutical product referenced in subparagraph (B) of\nparagraph two of subsection (e) of section forty-nine hundred of this\nchapter provided that coverage of the patient costs of such service has\nbeen recommended for the insured by an external appeal agent upon an\nappeal conducted pursuant to subparagraph (B) of paragraph four of\nsubsection (b) of section four thousand nine hundred fourteen of this\nchapter. The determination of the external appeal agent shall be binding\non the parties. For purposes of this paragraph, patient costs shall have\nthe same meaning as such term has for purposes of subparagraph (B) of\nparagraph four of subsection (b) of section four thousand nine hundred\nfourteen of this chapter; provided, however, that coverage for the\nservices required under this paragraph shall be provided subject to the\nterms and conditions generally applicable to other benefits provided\nunder the policy.\n  (23) If a policy provides for reimbursement for physical and\noccupational therapy service which is within the lawful scope of\npractice of a duly licensed physical or occupational therapist, an\ninsured shall be entitled to reimbursement for such service whether the\nsaid service is performed by a physician or through a duly licensed\nphysical or occupational therapist, provided however, that nothing\ncontained herein shall be construed to impair any terms of such policy\nincluding appropriate utilization review and the requirement that said\nservice be performed pursuant to a medical order, or a similar or\nrelated service of a physician.\n  (24)(A) Every policy which provides major medical or similar\ncomprehensive-type coverage shall include coverage for prehospital\nemergency medical services for the treatment of an emergency condition\nwhen such services are provided by an ambulance service issued a\ncertificate to operate pursuant to section three thousand five of the\npublic 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\nafflicted 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 organ\nor part of such person; (IV) serious disfigurement of such person; or\n(V) a condition described in clause (i), (ii), or (iii) of section\n1867(e)(1)(A) of the Social Security Act.\n  (25) (A) Every policy which provides coverage for hospital or surgical\ncoverage shall not exclude coverage for screening, diagnosis and\ntreatment of medical conditions otherwise covered by the policy solely\nbecause the treatment is provided to diagnose or treat autism spectrum\ndisorder.\n  (B) Every policy that provides physician services, medical, major\nmedical or similar comprehensive-type coverage shall provide coverage\nfor the screening, diagnosis and treatment of autism spectrum disorder\nin accordance with this paragraph and shall not exclude coverage for the\nscreening, diagnosis or treatment of medical conditions otherwise\ncovered by the policy because the individual is diagnosed with autism\nspectrum disorder. Such coverage may be subject to annual deductibles,\ncopayments and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the policy. This paragraph shall not be construed as\nlimiting the benefits that are otherwise available to an individual\nunder the policy, provided however that such policy shall not contain\nany limitations on visits that are solely applied to the treatment of\nautism spectrum disorder. No insurer shall terminate coverage or refuse\nto deliver, execute, issue, amend, adjust, or renew coverage to an\nindividual solely because the individual is diagnosed with autism\nspectrum disorder or has received treatment for autism spectrum\ndisorder. Coverage shall be subject to utilization review and external\nappeals of health care services pursuant to article forty-nine of this\nchapter as well as case management 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 policy\nfrom providing services through a network of participating providers who\nshall meet certain requirements for participation, including provider\ncredentialing.\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  (26)(A) No managed care health insurance policy that provides coverage\nfor hospital, medical or surgical care shall provide that services of a\nparticipating hospital will be covered as out-of-network services solely\non the basis that the health care provider admitting or rendering\nservices to the insured is not a participating provider.\n  (B) No managed care health insurance policy that provides coverage for\nhospital, medical or surgical care shall provide that services of a\nparticipating health care provider will be covered as out-of-network\nservices solely on the basis that the services are rendered in a\nnon-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  (27) 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  (28) 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 verify the prescription.\n  (29) Every individual policy which provides medical, major medical or\nsimilar comprehensive-type coverage that includes coverage for a\nphysical or well care visit once in every three hundred sixty-five days\nshall be interpreted to mean that such physical or well care visit can\nbe had once every calendar year, regardless of whether or not a period\nof three hundred sixty-five days has passed since the previous physical\nor well care visit.\n  * (30)(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  (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\nprograms and are similarly licensed, certified or otherwise authorized\nin 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  (D) 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 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 alcoholism and substance abuse services 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 alcoholism and\nsubstance abuse services. Prior to discharge, the facility shall\nindicate to the insurer whether services included in the discharge plan\nare secured or determined to be reasonably available. Any utilization\nreview of treatment provided under this subparagraph may include a\nreview of all services provided during such inpatient treatment,\nincluding all services provided during the first twenty-eight days of\nsuch inpatient treatment. Provided, however, the insurer shall only deny\ncoverage for any portion of the initial twenty-eight day inpatient\ntreatment on the basis that such treatment was not medically necessary\nif such inpatient treatment was contrary to the evidence-based and peer\nreviewed 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  (E) An insurer shall make available to any insured, prospective\ninsured, or in-network provider, upon request, the criteria for medical\nnecessity determinations under the policy with respect to inpatient\nsubstance use disorder benefits.\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  (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  * NB Effective until January 1, 2027\n  * (30)(A) Every policy that provides hospital, major medical or\nsimilar comprehensive 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  (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  (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 are\nlicensed, certified or otherwise authorized by the office of addiction\nservices and supports that are participating in the insurer's provider\nnetwork. Coverage provided under this paragraph shall not be subject to\npreauthorization. Coverage provided under this paragraph shall also not\nbe subject to concurrent utilization review during the first\ntwenty-eight days of the inpatient admission provided that the facility\nnotifies the insurer of both the admission and the initial treatment\nplan within two business days of the admission. The facility shall\nperform 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  (E) An insurer shall make available to any insured, prospective\ninsured, or in-network provider, upon request, the criteria for medical\nnecessity determinations under the policy with respect to inpatient\nsubstance-related and addictive disorder benefits.\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\nmeaning set forth in the most recent edition of the diagnostic and\nstatistical manual of mental disorders or the most recent edition of\nanother generally recognized independent standard of current medical\npractice, such as the international classification of diseases.\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  * NB Effective January 1, 2027\n  * NB There are 2 par (30)'s\n  * (30) Every policy that provides medical coverage that includes\ncoverage for physician services in a physician's office and every policy\nthat provides major medical or similar comprehensive-type coverage shall\ninclude coverage for equipment and supplies used for the treatment of\nostomies, if prescribed by a physician or other licensed health care\nprovider legally authorized to prescribe under title eight of the\neducation law. Such coverage shall be subject to annual deductibles and\ncoinsurance as deemed appropriate by the superintendent. The coverage\nrequired by this paragraph shall be identical to, and shall not enhance\nor increase the coverage required as part of essential health benefits\nas defined in subsection (a) of section three thousand two hundred\nseventeen-i of this article.\n  * NB There are 2 par (30)'s\n  * (31) (A) Every policy that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide outpatient coverage\nfor the diagnosis 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 substance abuse treatment programs and are similarly\nlicensed, certified, or otherwise authorized in the state in which the\nfacility 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  (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  * (31) (A) Every policy that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide outpatient coverage\nfor the diagnosis and treatment of substance-related and addictive\ndisorder, including detoxification and rehabilitation services. Such\ncoverage shall not apply financial requirements or treatment limitations\nto outpatient 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\nsubstance abuse treatment programs and are similarly licensed,\ncertified, or otherwise authorized in the state in which the facility is\nlocated.\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) 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\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  * (31-a) (A) No policy that provides medical, major medical or similar\ncomprehensive-type coverage and provides coverage for prescription drugs\nfor medication for the treatment of a substance use disorder shall\nrequire prior authorization for an initial or renewal prescription for\nthe detoxification or maintenance treatment of a substance use disorder,\nincluding all buprenorphine products, methadone, long acting injectable\nnaltrexone, or medication for opioid overdose reversal prescribed or\ndispensed to an insured covered under the policy, including federal food\nand drug administration-approved over-the-counter opioid overdose\nreversal medication as prescribed, dispensed or as otherwise authorized\nunder state or federal law, except where otherwise prohibited by law.\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  * NB Effective until January 1, 2027\n  * (31-a) (A) No policy that provides medical, major medical or similar\ncomprehensive-type coverage and provides coverage for prescription drugs\nfor medication for the treatment of a substance-related and addictive\ndisorder shall require prior authorization for an initial or renewal\nprescription for the detoxification or maintenance treatment of a\nsubstance-related and addictive disorder, including all buprenorphine\nproducts, methadone, long acting injectable naltrexone, or medication\nfor opioid overdose reversal prescribed or dispensed to an insured\ncovered under the policy, including federal food and drug\nadministration-approved over-the-counter opioid overdose reversal\nmedication as prescribed, dispensed or as otherwise authorized under\nstate or federal law, except where otherwise prohibited by law.\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  * NB Effective January 1, 2027\n  (31-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  (32) No policy delivered or issued for delivery in this state that\nprovides reimbursement for non-physician surgical first assistant\nservices when the services are provided by a non-physician surgical\nfirst assistant shall exclude such coverage on the basis that the\nnon-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  * (33) Every policy delivered or issued for delivery in this state\nthat provides coverage for prescription drugs subject to a copayment\nshall charge a copayment for a limited initial prescription of an opioid\ndrug, 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  * NB There are 2 par (33)'s\n  * (33) 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  * NB There are 2 par (33)'s\n  (34) 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  (35) (A) Every policy delivered or issued for delivery in this state\nthat provides coverage for inpatient hospital care or coverage for\nphysician services shall provide coverage for the diagnosis and\ntreatment of mental health conditions as follows:\n  * (i) where the policy provides coverage for inpatient hospital care,\nsuch policy shall include benefits for inpatient care in a hospital as\ndefined by subdivision ten of section 1.03 of the mental hygiene law and\nbenefits for outpatient care provided in 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 in a\nfacility operated by the office of mental health, or in a crisis\nstabilization center licensed pursuant to section 36.01 of the mental\nhygiene law, or, for care provided in other states, to similarly\nlicensed or certified hospitals or 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,\nsuch policy shall include benefits for: inpatient care in a hospital as\ndefined by subdivision ten of section 1.03 of the mental hygiene law;\nsub-acute care in a residential facility licensed or operated by the\noffice of mental health; outpatient care provided by a facility issued\nan operating certificate by the commissioner of mental health pursuant\nto the provisions of article thirty-one of the mental hygiene law or by\na facility 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, such\npolicy shall include benefits for outpatient care provided by a\npsychiatrist or psychologist licensed to practice in this state, 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 mental health counselor, marriage and family\ntherapist, or psychoanalyst licensed pursuant to article one hundred\nsixty-three of the education law, a nurse practitioner licensed to\npractice in this state, or a professional corporation or university\nfaculty practice corporation thereof. Nothing herein shall be construed\nto modify or expand the scope of practice of a mental health counselor,\nmarriage and family therapist, or psychoanalyst licensed pursuant to\narticle one hundred sixty-three of the education law. Further, nothing\nherein shall be construed to create a new mandated health benefit.\n  (B) Coverage required by this paragraph may be subject to annual\ndeductibles, copayments and coinsurance as may be deemed appropriate by\nthe superintendent and shall be consistent with those imposed on other\nbenefits 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\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  (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  * (36) (A) Every policy which provides hospital, surgical, or medical\ncoverage and which offers maternity coverage pursuant to paragraph ten\nof this subsection shall also provide coverage for abortion services for\nan 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) 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  * NB There are 2 par (36)'s\n  * (36)(A) Every policy that includes coverage for dialysis treatment\nthat requires such services to be provided by an in-network provider and\nthat does not provide coverage for out-of-network dialysis treatment\nshall not deny coverage of such services because the services are\nprovided by an out-of-network provider, provided that each of the\nfollowing 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  * NB There are 2 par (36)'s\n  * (37) Any policy that provides coverage for prescription drugs shall\napply any third-party payments, financial assistance, discount, voucher\nor other price reduction instrument for out-of-pocket expenses made on\nbehalf of an insured individual for the cost of a prescription drug 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  * (37) Any policy that provides coverage for prescription drugs shall\napply any third-party payments, financial assistance, discount, voucher\nor other price reduction instrument for out-of-pocket expenses made on\nbehalf of an insured individual for the cost of a prescription drug 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 (37)'s\n  * (37) (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 policy that provides coverage for prescription drugs shall\npermit each insured to fill any covered prescription that may be\nobtained at a network participating mail order or other non-retail\npharmacy, at the insured's option, at a network participating non-mail\norder retail pharmacy provided that the network participating non-mail\norder retail pharmacy agrees to the same reimbursement amount that the\ninsurer has established for the network participating mail order or\nother non-retail pharmacy. In such a case, the policy shall not impose a\nco-payment fee or other condition on any insured who elects to purchase\nprescription drugs from a network participating non-mail order retail\npharmacy which is not also imposed on insureds electing to purchase\ndrugs from a network participating mail order or other non-retail\npharmacy; provided, however, that the provisions of this subparagraph\nshall not supersede the terms of a collective bargaining agreement or\napply to a policy that is a result of a collective bargaining agreement\nbetween an employer and a recognized or certified employee organization.\n  * NB There are 2 par (37)'s\n  (38) Every policy that provides coverage for hospital, surgical or\nmedical care shall provide the following coverage for pasteurized donor\nhuman milk (PDHM), which may include fortifiers as medically indicated,\nfor which a licensed medical practitioner has issued an order for an\ninfant who is medically or physically unable to receive maternal breast\nmilk or participate in breast feeding or whose mother is medically or\nphysically unable to produce maternal breast milk at all or in\nsufficient quantities or participate in breast feeding despite optimal\nlactation support. Such infant shall: (i) have a documented birth weight\nof less than one thousand five hundred grams; or (ii) have a congenital\nor acquired condition that places the infant at a high risk for\ndevelopment of necrotizing enterocolitis.\n  * (39) No policy that provides coverage for antiretroviral\nprescription drugs prescribed for the treatment or prevention of the\nhuman immunodeficiency virus (HIV) or acquired immunodeficiency syndrome\n(AIDS) shall subject such drugs to prior authorization.\n  * NB There are 2 par (39)'s\n  * (39) (A) Every insurer issuing a 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 include 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  * NB There are 2 par (39)'s\n  (40) (A) 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 paragraph and shall not exclude coverage for the\nscreening, diagnosis or treatment of medical conditions otherwise\ncovered by the policy.\n  (B) Nothing in this paragraph 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  * (41) (A) Every policy which provides medical, major medical or\nsimilar comprehensive-type coverage and provides coverage for\nprescription drugs shall include coverage for inhalers for the treatment\nof asthma if prescribed by a physician or other licensed health care\nprovider legally authorized to prescribe under title eight of the\neducation 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 (41)'s\n  * (41) (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 (41)'s\n  (j) (1) Every insurer issuing a policy of accident and health\ninsurance 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. Such coverage\nshall be made available at the inception of all new policies and, with\nrespect to all other policies at any anniversary date of the policy\nsubject to evidence of insurability.\n  (A) In this paragraph nursing home care means the continued care and\ntreatment of a covered person who is under the care of a physician but\nonly if (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, (ii) the covered person has been in a\nhospital for at least three days immediately preceding admission, and\n(iii) further hospitalization would otherwise be necessary. The\naggregate of the number of covered days of care in a hospital and the\nnumber of covered days of care in a nursing home, with two days of care\nin a nursing home equivalent to one day of care in a hospital, may not\nexceed the number of covered days of hospital care provided under the\ncontract in a benefit period. The level of benefits to be provided for\nnursing home care must be reasonably related to the benefits provided\nfor hospital care.\n  (B) Ambulatory care means care in hospital out-patient facilities, as\na hospital is defined in section twenty-eight hundred one of the public\nhealth law or subchapter XVIII of the federal Social Security Act, 42\nU.S.C. §§ 1395 et seq, and physicians' offices. Ambulatory care in\nhospital out-patient facilities means services for diagnostic X-rays,\nlaboratory and pathological examinations, physical therapy and radiation\ntherapy, and services and medications used for nonexperimental cancer\nchemotherapy and cancer hormone therapy, provided that such services and\nmedications are (i) related to and necessary for the treatment or\ndiagnosis of the patient's illness or injury, (ii) ordered by a\nphysician and (iii) in the case of physical therapy, services are to be\nfurnished in connection with the same illness for which the patient had\nbeen hospitalized or in connection with surgical care, but in no event\nneed benefits be provided for physical therapy which commences more than\nsix months after discharge from a hospital or the date surgical care was\nrendered, and in no event need benefits for physical therapy be provided\nafter three hundred sixty-five days from the date of discharge from a\nhospital or the date surgical care was rendered. Ambulatory care in\nphysicians' offices means services for diagnostic X-rays, radiation\ntherapy, laboratory and pathological examinations, and services and\nmedications used for nonexperimental cancer chemotherapy and cancer\nhormone therapy, provided that such services and medications are related\nto and necessary for the treatment or diagnosis of the patient's illness\nor injury, and ordered by a physician. Such coverage shall be made\navailable at the inception of all new policies and, with respect to all\nother policies, at any anniversary date of the policy subject to\nevidence of insurability.\n  (2) Every insurer issuing a policy of accident and health insurance\nfor delivery in this state which provides coverage supplementing part A\nand part B of subchapter XVIII of the federal Social Security Act, 42\nU.S.C.  §§ 1395 et seq, must make available and, if requested by the\ninsured, provide coverage of supplemental home care visits beyond those\nprovided by part A and part B, sufficient to produce an aggregate\ncoverage of three hundred sixty-five home case visits per policy year.\nSuch coverage shall be provided pursuant to regulations prescribed by\nthe superintendent.\n  (3) Consistent with federal law, every insurer issuing a policy of\naccident and health insurance for delivery in this state which provides\ncoverage supplementing part A and part B of subchapter XVIII of the\nfederal Social Security Act, 42 USC §§ 1395 et seq., shall make\navailable and, if requested by the insured, 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 all\napplicants at the time of application for all new policies and\nthereafter on each anniversary date of the policy, and with respect to\nall other policies annually at each anniversary date of the policy. Such\nbrochures must be approved by the superintendent in consultation with\nthe commissioner of health.\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  (k) Any person, partnership or corporation willfully violating any\nprovision of this section, regulation or order of the superintendent\nmade in accordance with this section, shall forfeit to the people of the\nstate a sum not to exceed one hundred dollars for each such violation.\nThe superintendent may also suspend or revoke the license of an insurer\nor agent or broker for any such willful violation.\n  (l) An insurer shall not offer individual hospital, medical or\nsurgical expense insurance policies unless the policies meet the\nrequirements of subsection (b) of section four thousand three hundred\ntwenty-eight of this chapter. Such policies that are offered within the\nhealth benefit exchange established by this state also shall meet any\nrequirements established by the health benefit exchange.\n  (m) 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 as essential health benefits. For any policy\nissued within the health benefit exchange established by this state, an\ninsurer shall not be required to offer the policyholder any benefits\nthat must be made available pursuant to this section. For purposes of\nthis subsection, "essential health benefits" shall have the meaning set\nforth in subsection (a) of section three thousand two hundred\nseventeen-i of this article.\n  * (n) 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