Source: http://dfs.ny.gov/insurance/health/lbenall.htm
Timestamp: 2014-10-02 16:29:30
Document Index: 382595620

Matched Legal Cases: ['§3221', '§3216', '§4303', '§4303', '§3221', '§3216', '§4303', '§4303', '§3221', '§3216', '§4303', '§4303', '§3221', '§3216', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§3221', '§3221', '§3216', '§4303', '§4303', '§4805', '§4805', '§4805', '§4406', '§4805', '§3321', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§ 4321', '§4322', '§4303', '§4406', '§3221', '§3216', '§4303', '§4303', '§3221', '§3216', '§4303', '§4303', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§3221', '§4303', '§4303', '§3221', '§4303', '§4303', '§3221', '§4303', '§4303', '§3221', '§3216', '§4303']

Mandated and Make Available Benefits: Commercial, HMO & Article 43 Insurance
Mandated and Make Available Benefits: Commercial, HMO & Article 43 Insurance Contracts
The following tables provide the citations to the Insurance Law for health insurance benefits. The benefit listing is current through March 1, 2012. Please note that each statute must be consulted to find if there are additional criteria for the benefit to be mandated for inclusion in a particular type of insurance contract. This information is also available in PDF format.
A. Mandated Benefits for Inclusion in Group Commercial, Blanket Commercial, Individual Commercial, Group HMO & Article 43 Insurance Contracts
BenefitGroup CommercialBlanket CommercialIndividual CommercialGroup HMOArticle 43 Home health care
§3221(k)(1) N/A §3216(i)(6) §4303(a)(3) §4303(a)(3) Preadmission testing §3221(k)(2) N/A §3216(i)(7) §4303(a)(1) §4303(a)(1) Second surgical opinion §3221(k)(3) N/A §3216(i)(8) §4303(b) §4303(b) Emergency medical services §3221(k)(4) See also: Circular Letter No. 1 (2002)
N/A §3216(i)(9) See also: Circular Letter No. 1 (2002)
§4303(a)(2) See also: Circular Letter No. 1 (2002)
Maternity care §3221(k)(5) §3221(k)(5) §3216(i)(10) §4303(c) §4303(c) Medical conditions leading to infertility §3221(k)(6) N/A §3216(i)(13) §4303(s) §4303(s) Diabetic supplies, equipment, and self-management education
§3221(k)(7) §3221(k)(7) §3216(i)(15-a) §4303(u) §4303(u) Mastectomy care §3221(k)(8) §3221(k)(8) §3216(i)(18) §4303(v) §4303(v) Second medical opinion for cancer diagnosis §3221(k)(9) §3221(k)(9) §3216(i)(19) §4303(w) §4303(w) Post-mastectomy reconstruction §3221(k)(10) §3221(k)(10) §3216(i)(20) §4303(x) §4303(x) Enteral Formulas §3221(k)(11) §3221(k)(11) §3216(i)(21) §4303(y) §4303(y) Chiropractic care §3221(k)(11) §3221(k)(11) §3216(i)(21) §4303(y) §4303(y) Experimental or investigational services recommended by an external appeal agent §3221(k)(12) §3221(k)(12) §3216(i)(22) §4303(z) §4303(z) Chemical abuse and dependence (outpatient) §3221(l)(7) §3221(l)(7) N/A §4303(l) §4303(l) Preventive and primary care §3221(l)(8) N/A §3216(i)(17) §4303(j) §4303(j) Mammography screening §3221(l)(11) §3221(l)(11) §3216(i)(11) §4303(p) §4303(p) Prostate cancer screening §3221(l)(11-a) §3221(l)(11-a) §3216(i)(11-a) §4303(z-1) §4303(z-1) Cancer drugs §3221(l)(12) §3221(l)(12) §3216(i)(12) §4303(q) §4303(q) Cervical cytology screening §3221(l)(14) §3221(l)(14) §3216(i)(15) §4303(t) §4303(t) Pre-hospital emergency medical services §3221(l)(15) §3221(l)(15) §3216(i)(24) §4303(aa) §4303(aa) End of life care §4805 §4805 §4805 Public Health Law §4406-e §4805 Infertility coverage §3321(k)(6) N/A N/A §4303(s) §4303(s) Bone density measurements, testing , drugs, and devices
§3221(k)(13) §3221(k)(13) N/A §4303(bb) §4303(bb) Contraceptive drugs and devices §3221(l)(16) §3221(l)(16) N/A §4303 (cc) §4303 (cc) Eating Disorders §3221(k)(14) §3221(k)(14) N/A §4303(dd) §4303(dd) Mental, nervous or emotional disorders or ailments §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h) Biologically based mental illness and serious emotional disturbances (large groups) §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h) Autism Spectrum*
[Statutes change effective 11/1/2012]
§3221(l)(17) §3221(l)(17) 3216(i)(25) §4303(ee) §4303(ee) B. Mandated Benefits for Inclusion in Individual Direct Pay HMO Contracts  §§ 4321 & 4322
The table below identifies the benefits and general information on the scope of the benefit in a standardized individual direct pay contract. However, unless Insurance Law §4322(b) expressly changes the requirements, Insurance Law §4303 should be consulted for the parameters of each benefit.
ServiceScope Inpatient hospital services Room & boardGeneral nursing careSpecial dietsMiscellaneous hospital services Outpatient hospital services Diagnostic & treatment servicesX-raysLaboratory tests Physician services Consultant & referral services, includes a second medical opinion for cancer diagnosis Primary & preventive careIn-hospital medical services, includes mastectomy careSurgical services, includes mastectomy reconstructionAnesthetic servicesSecond surgical opinion Preventive health services Periodic physical exams, including eye and ear examsWell child care ImmunizationsMammography screeningCervical cytology screening Emergency services Emergency medical services provided in a hospital Diagnostic laboratory services Radiology services Therapeutic Diagnostic Preadmission testing Home health care Up to 200 visits per calendar year Maternity care Chemotherapy services Hemodialysis services Outpatient physical therapy Up to 90 visits per condition per calendar year Hospice care Up to 210 days Skilled nursing facility care When preceded by a hospital stay of at least three (3) days and further hospitalization would otherwise be necessary. Diabetic treatment EquipmentSuppliesEducation Inpatient mental health care 30 days per calendar year (offset by chemical abuse treatment) Outpatient mental health Up to 30 non-emergency visits & 3 emergency visits per calendar year Inpatient alcoholism & substance abuse Up to 30 days per calendar year for detoxification (offset by inpatient mental health care) Ambulance services Private duty nursing Up to $5,000 per calendar year; $10,000 lifetime maximum Durable medical equipment ProstheticsOrthoticsDurable medical equipmentMedical supplies Inpatient physical rehabilitation services Blood & blood products Prescription drugs Includes enteral formulas, cancer drugs, and contraceptive drugs and devicesPharmacyMail order Bone density measurements, testing , drugs, and devices Experimental or investigational services recommended by an external appeal agent End of life care* Eating Disorders * See Public Health Law §4406-e
C. Make Available Benefits for Inclusion in Group Commercial, Blanket Commercial, Individual Commercial, Group HMO & Article 43 Insurance Contracts
BenefitGroup CommercialBlanket CommercialIndividual CommercialGroup
HMOArticle 43 Nursing home care
§3221(l)(2) N/A §3216(j)(1)(A) §4303(d) §4303(d) and (r) Ambulatory care §3221(l)(3) N/A §3216(j)(1)(B) §4303(e) and (f) §4303(e) and (f) Social worker §3221(l)(4) N/A N/A §4303(i) §4303(i) Biologically based mental illness and serious emotional disturbances (small groups) §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h) Inpatient treatment of alcoholism and substance abuse
§3221(l)(6) §3221(l)(6) N/A §4303(k) §4303(k) Registered nurse §3221(l)(9) N/A N/A §4303(m) §4303(m) Hospice care §3221(l)(10) N/A N/A §4303(o) §4303(o) Supplemental home care §3221(l)(1) N/A §3216(j)(2) N/A §4303(a)(3)(D) AccessibilityContact UsDisclaimerPrivacy PolicySite Map