NY Ins L § 4303 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4303 - Benefits.

§  4303.  Benefits.  (a)  Every  contract issued by a hospital service corporation or health service corporation which  provides  coverage  for in-patient hospital care shall also provide coverage:  (1) For preadmission testing performed in hospital facilities prior to scheduled  surgery.  A  patient who uses the out-patient facilities of a hospital shall be entitled to benefits for tests ordered by a  physician which are performed as a planned preliminary to admission of the patient as an in-patient for surgery in the same hospital, provided that:  (A)  tests  are  necessary  for  and consistent with the diagnosis and treatment of the condition for which surgery is to be performed,  (B) reservations for a hospital bed and for an  operating  room  shall have been made prior to the performance of the tests,  (C) surgery actually takes place within seven days of such presurgical tests, and  (D) the patient is physically present at the hospital for the tests.  (2)  (A)  For  services  to  treat  an emergency condition in hospital facilities:  (i) without the need for any prior authorization determination;  (ii) regardless of whether the health care  provider  furnishing  such services is a participating provider with respect to such services;  (iii)  if  the  emergency services are provided by a non-participating provider, without imposing any administrative requirement or  limitation on   coverage   that  is  more  restrictive  than  the  requirements  or limitations that apply to emergency services received from participating providers; and  (iv) if the emergency services are  provided  by  a  non-participating provider,  the  cost-sharing  requirement  (expressed  as a copayment or coinsurance) shall be the same requirement  that  would  apply  if  such services were provided by a participating provider.  (B)  Any requirements of section 2719A(b) of the Public Health Service Act, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed  the requirements  of  this  paragraph  with respect to coverage of emergency services  shall  be  applicable  to  every  contract  subject  to   this paragraph.  (C)  For  the purpose of this provision, "emergency condition" means a medical or behavioral condition that manifests itself by acute  symptoms of  sufficient  severity,  including  severe  pain,  such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention  to  result in (i) placing the health of the person afflicted with such condition in serious  jeopardy,  or in the case of a behavioral condition placing the health of such person  or  others  in  serious  jeopardy;  (ii)  serious impairment  to such person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; (iv)  serious  disfigurement of  such  person;  or  (v)  a condition described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the Social Security Act.  (D) For the purpose of this  provision,  "emergency  services"  means, with  respect  to  an  emergency  condition:  (i)  a  medical  screening examination as required under section 1867 of the Social  Security  Act, 42  U.S.C.  §  1395dd,  which  is within the capability of the emergency department  of  a  hospital,  including  ancillary  services   routinely available to the emergency department to evaluate such emergency medical condition;  and (ii) within the capabilities of the staff and facilities available  at  the  hospital,  such  further  medical  examination   and treatment as are required under section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, to stabilize the patient.  (E)  For  the  purpose  of  this provision, "to stabilize" means, with respect to an emergency condition, to provide such medical treatment  of  the  condition  as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition  is  likely to  result  from  or  occur during the transfer of the subscriber from a facility or to deliver a newborn child (including the placenta).  (3)  For home care to residents in this state. Such home care coverage shall be included at the  inception  of  all  new  contracts  and,  with respect  to  all  other  contracts, added at any anniversary date of the contract subject to evidence  of  insurability.  Such  coverage  may  be subject  to an annual deductible of not more than fifty dollars for each covered person and may be  subject  to  a  coinsurance  provision  which provides  for  coverage  of  not  less  than seventy-five percent of the reasonable cost of services for which  payment  may  be  made.  No  such corporation need provide such coverage to persons eligible for medicare.  (A)  Home  care  shall mean the care and treatment of a covered person who is under the care of a physician but only if:  (i) hospitalization or confinement in a nursing facility as defined in subchapter XVIII of the Social Security Act, 42 U.S.C. §  1395  et  seq, would otherwise have been required if home care was not provided, and  (ii)  the  plan  covering  the  home health service is established and approved in writing by such physician.  (B) Home care shall be  provided  by  an  agency  possessing  a  valid certificate of approval or license issued pursuant to article thirty-six of the public health law.  (C) Home care shall consist of one or more of the following:  (i)  part-time  or  intermittent  home  nursing  care  by or under the supervision of a registered professional nurse (R.N.),  (ii) part-time or intermittent home health aide services which consist primarily of caring for the patient,  (iii) physical, occupational or speech therapy if provided by the home health service or agency, and  (iv)  medical  supplies,  drugs  and  medications  prescribed   by   a physician,  and  laboratory services by or on behalf of a certified home health agency or licensed home care services agency to the  extent  such items  would  have  been  covered  or provided under the contract if the covered person had been hospitalized or confined in  a  skilled  nursing facility  as  defined in subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq.  (D) For  the  purpose  of  determining  the  benefits  for  home  care available  to  a  covered  person, each visit by a member of a home care team shall be considered as  one  home  care  visit.  The  contract  may contain  a  limitation  on  the number of home care visits, but not less than forty such visits in any calendar year or in any continuous  period of  twelve  months,  for  each covered person. Four hours of home health aide service shall be considered as one home care visit. Every  contract issued  by  a hospital service corporation or health service corporation which provides coverage supplementing part A and part  B  of  subchapter XVIII  of  the  Social  Security Act, 42 U.S.C. § 1395 et seq, must make available and, if requested by a subscriber  holding  a  direct  payment contract  or  by  all  subscribers in a group remittance group or by the contract holder in the  case  of  group  contracts  issued  pursuant  to section  four  thousand  three  hundred  five  of  this article, provide coverage of supplemental home care visits beyond those provided by  part A  and  part  B,  sufficient  to  produce an aggregate coverage of three hundred sixty-five home care visits per  contract  year.  Such  coverage shall   be   provided   pursuant   to   regulations  prescribed  by  the superintendent. Written notice of  the  availability  of  such  coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that  this  notice  shall not be required where a policy covers two hundred or more employees or  where  the  benefit  structure  was  the  subject  of collective  bargaining  affecting  persons who are employed in more than one state.   The provisions of this subsection shall not apply to a contract issued pursuant  to  section  four  thousand three hundred five of this article which covers persons employed in more than  one  state  or  the  benefit structure  of  which  was the subject of collective bargaining affecting persons who are employed in more than one state.  (b) Every contract issued by a medical expense  indemnity  corporation or  a  health service corporation which provides coverage for in-patient surgical care shall include coverage for a second surgical opinion by  a qualified  physician on the need for surgery, except that this provision shall not apply to a contract issued pursuant to section  four  thousand three hundred five of this article which covers persons employed in more than  one  state  or  the  benefit structure of which was the subject of collective bargaining affecting persons who are employed  in  more  than one state.  (c)  (1)  (A)  Every  contract  issued by a corporation subject to the provisions of this article  which  provides  hospital  service,  medical expense  indemnity  or  both  shall  provide coverage for maternity care including hospital, surgical or medical care to  the  same  extent  that hospital  service,  medical  expense  indemnity or both are provided for illness or disease under the contract.  Such  maternity  care  coverage, other than coverage for perinatal complications, shall include inpatient hospital  coverage  for  mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean  section, and  for  at  least ninety-six hours following a caesarean section. Such coverage for maternity care shall include  the  services  of  a  midwife licensed  pursuant  to  article  one hundred forty of the education law, practicing consistent with section sixty-nine hundred fifty-one  of  the education  law  and  affiliated  or  practicing  in  conjunction  with a facility licensed pursuant to article twenty-eight of the public  health law,  but  no  insurer  shall be required to pay for duplicative routine services actually provided by both a licensed midwife and a physician.  (B) Maternity care coverage also shall  include,  at  minimum,  parent education,  assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn clinical assessments.  (C) The mother shall have the option to be discharged earlier than the time periods established in subparagraph (A) of this paragraph. In  such case,  the  inpatient  hospital  coverage must include at least one home care visit, which shall be in addition to, rather than in lieu  of,  any home  health  care  coverage  available under the contract. The contract must cover the home care visit which may be requested at any time within forty-eight hours of the time of delivery (ninety-six hours in the  case of  caesarean section), and shall be delivered within twenty-four hours, (i) after discharge, or (ii)  of  the  time  of  the  mother's  request, whichever  is  later.  Such  home care coverage shall be pursuant to the contract and subject to  the  provisions  of  this  paragraph,  and  not subject to deductibles, coinsurance or copayments.  (2)  Coverage  provided  under  this subsection for care and treatment during pregnancy shall include provision for not less than two payments, at reasonable intervals and for services rendered, for prenatal care and a separate payment for the delivery and postnatal care provided.  (d) (1) A hospital service corporation or a health service corporation which provides coverage for in-patient hospital care must make available and, if requested by  a  person  holding  a  direct  payment  individual contract or by all persons holding individual contracts in a group whose  premiums  are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to section four thousand  three hundred  five  of  this  article,  provide  coverage for care in nursing homes. Such coverage shall be made available at the inception of all new contracts  and,  with respect to all other contracts, at any anniversary date  subject  to  evidence  of  insurability.  Written  notice  of  the availability  of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such  contract  and annually thereafter, except that this notice shall not be required where a  policy  covers  two  hundred  or  more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (2) For the purpose of this subsection, care in  nursing  homes  shall mean  the  continued care and treatment of a covered person who is under the care of a physician but only if  (i)  the  care  is  provided  in  a nursing home as defined in section two thousand eight hundred one of the public health law or a skilled nursing facility as defined in subchapter XVIII  of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii) the covered person has been in  a  hospital  for  at  least  three  days immediately  preceding  admittance  to  the  nursing home or the skilled nursing facility, and (iii) further hospitalization would  otherwise  be necessary.  The  aggregate  of  the  number of covered days of care in a hospital and the number of covered days of care in a nursing home,  with two  days  of  care in a nursing home equivalent to one day of care in a hospital, need not exceed the number of covered days  of  hospital  care provided  under  the contract in a benefit period. The level of benefits to be provided for nursing home care must be reasonably related  to  the benefits provided for hospital care.  (e) (1) A hospital service corporation or a health service corporation which provides coverage for in-patient hospital care must make available and,  if  requested  by  a  person  holding  a direct payment individual contract or by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contract holder in  the case  of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for  ambulatory  care  in hospital out-patient facilities, as a hospital is defined in section two thousand eight hundred one of the public health law, or subchapter XVIII of  the  Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of the availability of such  coverage  shall  be  delivered  to  the  group remitting  agent  or  group  contract  holder prior to inception of such contract and annually thereafter, except that this notice shall  not  be required  where  a  policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (2) For the purpose of this subsection, ambulatory  care  in  hospital out-patient  facilities  shall  mean  services  for  diagnostic  x-rays, laboratory and  pathological  examinations,  physical  and  occupational therapy  and  radiation  therapy,  and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and medications are (i) related to and necessary  for the  treatment  or  diagnosis  of  the patient's illness or injury, (ii) ordered by a physician and  (iii)  in  the  case  of  physical  therapy, services  are  to  be  furnished in connection with the same illness for which the patient had been hospitalized or in connection  with  surgical care,  but  in  no  event need benefits for physical therapy be provided which commences more than six months after discharge from a hospital  or the  date  surgical care was rendered, and in no event need benefits for physical therapy be provided after three hundred  sixty-five  days  from  the  date  of  discharge  from  a hospital or the date surgical care was rendered. Such coverage shall be made available at the inception of  all new  contracts  and,  with  respect  to  all  other  contracts,  at  any anniversary date subject to evidence of insurability.  (f)  (1)  A  medical expense indemnity corporation or a health service corporation which provides coverage for physicians' services  must  make available  and,  if  requested  by a person holding an individual direct payment contract or by all persons holding  individual  contracts  in  a group  whose  premiums  are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to  section  four thousand  three  hundred  five  of  this  article,  provide coverage for ambulatory  care  in  physicians'  offices.  Written   notice   of   the availability  of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such  contract  and annually thereafter, except that this notice shall not be required where a  policy  covers  two  hundred  or  more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (2) For the purpose of this subsection, ambulatory care in physicians' offices shall mean services for diagnostic  x-rays,  radiation  therapy, laboratory  and  pathological examinations, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and  medications  are  (i)  related  to  and necessary  for  the  treatment  or diagnosis of the patient's illness or injury, and (ii) ordered by a physician. Such  coverage  shall  be  made available at the inception of all new contracts and, with respect to all other   contracts  at  any  anniversary  date  subject  to  evidence  of insurability.  (g)  A  medical  expense  indemnity  corporation,   hospital   service corporation  or a health service corporation, that provides group, group remittance or school blanket coverage for  inpatient  hospital  care  or coverage  for  physician  services shall provide as part of its contract coverage for the diagnosis and treatment  of  mental  health  conditions and:  (1)  where the contract provides coverage for inpatient hospital care, benefits for in-patient care in a hospital as defined by subdivision ten of section 1.03 of the mental hygiene law or for inpatient care provided in other states, to  similarly  licensed  hospitals,  and  benefits  for out-patient  care provided in a facility issued an operating certificate by the commissioner of mental  health  pursuant  to  the  provisions  of article  thirty-one  of the mental hygiene law or in a facility operated by the office of mental health  or  in  a  crisis  stabilization  center licensed  pursuant  to  section  36.01  of the mental hygiene law or for out-patient care  provided  in  other  states,  to  similarly  certified facilities; and  (2)  where  the  contract  provides  coverage  for  physician services benefits for outpatient care provided by a psychiatrist or  psychologist licensed  to  practice  in this state, a licensed clinical social worker who meets the requirements of subsection (n) of this  section,  a  nurse practitioner  licensed  to  practice  on  this  state,  or  professional corporation or university faculty practice corporation thereof.  (3) Such coverage may be subject to annual  deductibles,  co-pays  and coinsurance as may be deemed appropriate by the superintendent and shall be  consistent  with those imposed on other benefits under the contract. Provided that no copayment or coinsurance imposed for outpatient  mental health  services provided in a facility licensed, certified or otherwise authorized by the office of mental health shall exceed the copayments or coinsurance imposed for a primary care office visit under the contract.  (4)  Coverage  under  this  subsection  shall  not   apply   financial requirements or treatment limitations to mental health benefits that are more   restrictive  than  the  predominant  financial  requirements  and treatment limitations applied to substantially all medical and  surgical benefits covered by the contract.  (5)  The  criteria  for  medical  necessity  determinations  under the contract with respect to mental health benefits shall be made  available by  the  corporation  to any insured, prospective insured, or in-network provider upon request.  (6) For purposes of this subsection:  (A) "financial requirement" means deductible, copayments,  coinsurance and out-of-pocket expenses;  (B)  "predominant"  means  that  a  financial requirement or treatment limitation is the most common or frequent  of  such  type  of  limit  or requirement;  (C) "treatment limitation" means limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or   duration   of  treatment  and  includes  nonquantitative  treatment limitations such as: medical management standards limiting or  excluding benefits  based  on medical necessity, or based on whether the treatment is experimental or investigational; formulary  design  for  prescription drugs;   network  tier  design;  standards  for  provider  admission  to participate in a network, including  reimbursement  rates;  methods  for determining usual, customary, and reasonable charges; fail-first or step therapy  protocols;  exclusions based on failure to complete a course of treatment; and restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or  duration of benefits for services provided under the contract; and  (D)  "mental  health  condition"  means  any mental health disorder as defined in the most recent edition of  the  diagnostic  and  statistical manual  of  mental  disorders  or  the  most  recent  edition of another generally recognized independent standard of  current  medical  practice such as the international classification of diseases.  (7)  A  corporation shall provide coverage under this subsection, at a minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. § 1185a).  (8) This paragraph shall apply to hospitals in  this  state  that  are licensed  by  the  office of mental health that are participating in the corporation's provider network. Where the contract provides coverage for inpatient hospital care, benefits  for  inpatient  hospital  care  in  a hospital  as  defined  by  subdivision ten of section 1.03 of the mental hygiene law provided to individuals who have not  attained  the  age  of eighteen  shall  not  be  subject to preauthorization. Coverage provided under this paragraph shall also not be subject to concurrent utilization review during the  first  fourteen  days  of  the  inpatient  admission, provided the facility notifies the corporation of both the admission and the  initial  treatment  plan within two business days of the admission, performs daily clinical review  of  the  patient,  and  participates  in periodic  consultation  with the corporation to ensure that the facility is using the evidence-based and peer reviewed clinical  review  criteria utilized  by  the  corporation which is approved by the office of mental health and appropriate to the age of the patient,  to  ensure  that  the inpatient  care  is  medically  necessary for the patient. All treatment provided under this paragraph may  be  reviewed  retrospectively.  Where care  is denied retrospectively, an insured shall not have any financial obligation to the facility for any treatment under this paragraph  other  than  any copayment, coinsurance, or deductible otherwise required under the contract.  (9) This paragraph shall apply to crisis stabilization centers in this state  that are licensed pursuant to section 36.01 of the mental hygiene law and participate in the corporation's provider network. Benefits  for care   in  a  crisis  stabilization  center  shall  not  be  subject  to preauthorization. All treatment provided under  this  paragraph  may  be reviewed  retrospectively.  Where  care  is  denied  retrospectively, an insured shall not have any financial obligation to the facility for  any treatment under this paragraph other than any copayment, coinsurance, or deductible otherwise required under the contract.  (i)   A  medical  expense  indemnity  corporation  or  health  service corporation that provides  coverage  for  physicians,  psychiatrists  or psychologists  for  psychiatric  or  psychological  services  or for the diagnosis and treatment of mental health conditions, however defined  in such  contract,  shall  make  available  and if requested by all persons holding individual contracts in a group whose premiums  are  paid  by  a remitting  agent  or  by  the  contract  holder  in  the case of a group contract issued pursuant to section four thousand three hundred five  of this article, provide the same coverage for such services when performed by  a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to article one hundred fifty-four of the education law. The state board for social work shall  maintain  a list of all licensed clinical social workers qualified for reimbursement under  this  subsection.  Such  coverage  shall be made available at the inception of all new contracts and, with respect to all other contracts, at any anniversary date subject to  evidence  of  insurability.  Written notice  of  the  availability of such coverage shall be delivered to the group remitting agent or group contract holder  prior  to  inception  of such contract and annually thereafter, except that this notice shall not be  required  where  a  contract covers two hundred or more employees or where the benefit structure was the  subject  of  collective  bargaining affecting persons who are employed in more than one state.  (j)(1)  A  health  service  corporation  or  medical expense indemnity corporation   that   provides   medical,   major-medical   or    similar comprehensive-type  coverage shall provide coverage for the provision of preventive and primary care services.  (2)  For  purposes  of  this  paragraph  and  paragraph  one  of  this subsection,   preventive  and  primary  care  services  shall  mean  the following services rendered to a covered child of a subscriber from  the date of birth through the attainment of nineteen years of age:  (A)  an  initial  hospital check-up and well-child visits scheduled in accordance  with  the  prevailing  clinical  standards  of  a   national association  of  pediatric  physicians designated by the commissioner of health (except for any standard that would limit the specialty or  forum of  licensure  of  the practitioner providing the service other than the limits under state law). Coverage for such services  rendered  shall  be provided  only to the extent that such services are provided by or under the supervision of a physician, or  other  professional  licensed  under article  one  hundred  thirty-nine  of  the education law whose scope of practice pursuant to such law includes  the  authority  to  provide  the specified  services.  Coverage  shall  be  provided  for  such  services rendered in a hospital, as defined in section twenty-eight  hundred  one of  the  public  health  law,  or  in  an office of a physician or other professional licensed under  article  one  hundred  thirty-nine  of  the education  law whose scope of practice pursuant to such law includes the authority to provide the specified services,  (B) at each visit, services in accordance with the prevailing clinical standards of such designated association, including a medical history, a complete physical examination,  developmental  assessment,  anticipatory guidance, appropriate immunizations and laboratory tests which tests are ordered  at  the  time  of the visit and performed in the practitioner's office, as authorized by law, or in a clinical laboratory, and  (C) necessary immunizations, as determined by  the  superintendent  in consultation  with  the  commissioner  of health, consisting of at least adequate dosages of  vaccine  against  diphtheria,  pertussis,  tetanus, polio,  measles,  rubella,  mumps,  haemophilus  influenzae  type  b and hepatitis b, which meet the standards  approved  by  the  United  States public health service for such biological products.  (D)  Such  coverage  required pursuant to this paragraph and paragraph one of this subsection shall not be subject  to  annual  deductibles  or coinsurance.  (E)  Such  coverage  required pursuant to this paragraph and paragraph one of this subsection shall not restrict or eliminate existing coverage provided by the contract.  (3) In addition to paragraph one or  two  of  this  subsection,  every contract  that  provides  hospital,  surgical  or medical care coverage, except for a grandfathered health plan  under  paragraph  four  of  this subsection, shall provide coverage for the following preventive care and screenings  for  subscribers,  and such coverage shall not be subject to annual deductibles or coinsurance:  (A)  evidence-based  items  or  services  for  preventive   care   and screenings  that  have  in  effect a rating of 'A' or 'B' in the current recommendations of the United States preventive services task force;  (B) immunizations that  have  in  effect  a  recommendation  from  the advisory  committee on immunization practices of the centers for disease control and prevention with respect to the individual involved;  (C) with respect  to  children,  including  infants  and  adolescents, evidence-informed   preventive  care  and  screenings  provided  for  in comprehensive guidelines supported by the health resources and  services administration; and  (D)  with  respect  to  women,  such  additional  preventive  care and screenings not described in subparagraph (A) of this  paragraph  and  as provided  for  in  comprehensive  guidelines  supported  by  the  health resources and services administration.  (4) For purposes of this subsection, "grandfathered health plan" means coverage provided by a corporation in which an individual  was  enrolled on  March  twenty-third,  two  thousand  ten for as long as the coverage maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).  (k)(1) Every contract that provides hospital, major medical or similar comprehensive  coverage  shall  provide  inpatient  coverage   for   the diagnosis   and   treatment   of   substance   use  disorder,  including detoxification and  rehabilitation  services.  Such  inpatient  coverage shall  include unlimited medically necessary treatment for substance use disorder treatment services provided in residential  settings.  Further, such  inpatient  coverage  shall  not  apply  financial  requirements or treatment limitations, including  utilization  review  requirements,  to inpatient substance use disorder benefits that are more restrictive than the predominant financial requirements and treatment limitations applied to  substantially  all  medical  and  surgical  benefits  covered by the contract.  (2)  Coverage  provided  under  this  subsection  may  be  limited  to facilities  in  New York state that are licensed, certified or otherwise authorized by the office of alcoholism and substance abuse services and,  in other states, to those which are accredited by the  joint  commission as   alcoholism,  substance  abuse,  or  chemical  dependence  treatment programs and are similarly licensed, certified or  otherwise  authorized in the state in which the facility is located.  (3)  Coverage  provided under this subsection may be subject to annual deductibles and co-insurance as deemed appropriate by the superintendent and that are consistent with those imposed on other  benefits  within  a given contract.  (4)  This  paragraph  shall apply to facilities in this state that are licensed, certified or otherwise authorized by the office of  alcoholism and substance abuse services that are participating in the corporation's provider  network.  Coverage provided under this subsection shall not be subject to preauthorization. Coverage  provided  under  this  subsection shall  also  not  be subject to concurrent utilization review during the first twenty-eight days of the inpatient  admission  provided  that  the facility  notifies the corporation of both the admission and the initial treatment plan within two business days of the admission.  The  facility shall  perform  daily clinical review of the patient, including periodic consultation with the corporation at or just prior to the fourteenth day of treatment to ensure that the facility is using the evidence-based and peer reviewed clinical review tool utilized by the corporation which  is designated  by the office of alcoholism and substance abuse services and appropriate to the age of the patient,  to  ensure  that  the  inpatient treatment  is  medically  necessary for the patient. Prior to discharge, the facility shall provide  the  patient  and  the  corporation  with  a written  discharge plan which shall describe arrangements for additional services needed following  discharge  from  the  inpatient  facility  as determined  using  the  evidence-based and peer-reviewed clinical review tool utilized by the corporation which is designated by  the  office  of alcoholism  and  substance  abuse  services.  Prior  to  discharge,  the facility shall indicate to the corporation whether services included  in the discharge plan are secured or determined to be reasonably available. Any  utilization  review  of treatment provided under this paragraph may include  a  review  of  all  services  provided  during  such  inpatient treatment, including all services provided during the first twenty-eight days  of  such  inpatient  treatment. Provided, however, the corporation shall only deny coverage for any portion of the initial twenty-eight day inpatient treatment on the basis that such treatment was  not  medically necessary if such inpatient treatment was contrary to the evidence-based and peer reviewed clinical review tool utilized by the corporation which is  designated by the office of alcoholism and substance abuse services. An insured shall not have any financial obligation to the  facility  for any   treatment   under   this   paragraph  other  than  any  copayment, coinsurance, or deductible otherwise required under the contract.  (5) The  criteria  for  medical  necessity  determinations  under  the contract with respect to inpatient substance use disorder benefits shall be made available by the corporation to any insured, prospective insured or in-network provider upon request.  (6) For purposes of this subsection:  (A)  "financial requirement" means deductible, copayments, coinsurance and out-of-pocket expenses;  (B) "predominant" means that  a  financial  requirement  or  treatment limitation  is  the  most  common  or  frequent of such type of limit or requirement;  (C) "treatment limitation" means limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or  duration  of  treatment  and  includes   nonquantitative   treatment limitations  such as: medical management standards limiting or excluding  benefits based on medical necessity, or based on whether  the  treatment is  experimental  or  investigational; formulary design for prescription drugs;  network  tier  design;  standards  for  provider  admission   to participate  in  a  network,  including reimbursement rates; methods for determining usual, customary, and reasonable charges; fail-first or step therapy protocols; exclusions based on failure to complete a  course  of treatment; and restrictions based on geographic location, facility type, provider  specialty, and other criteria that limit the scope or duration of benefits for services provided under the contract; and  (D) "substance use disorder" shall have the meaning set forth  in  the most  recent  edition of the diagnostic and statistical manual of mental disorders or the most recent edition  of  another  generally  recognized independent   standard   of   current   medical  practice  such  as  the international classification of diseases.  (7) A corporation shall provide coverage under this subsection,  at  a minimum,  consistent  with  the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity  Act  of  2008  (29  U.S.C.  § 1185a).  (l) (1) Every contract that provides medical, major medical or similar comprehensive-type  coverage  shall  provide outpatient coverage for the diagnosis  and  treatment   of   substance   use   disorder,   including detoxification  and  rehabilitation  services.  Such  coverage shall not apply financial requirements  or  treatment  limitations  to  outpatient substance  use  disorder  benefits  that  are  more restrictive than the predominant financial requirements and treatment limitations applied  to substantially all medical and surgical benefits covered by the contract.  (2)  Coverage  under  this  subsection may be limited to facilities in this state that are licensed, certified or otherwise authorized  by  the office   of  addiction  services  and  supports  to  provide  outpatient substance  use  disorder  services  and  crisis  stabilization   centers licensed  pursuant  to  section 36.01 of the mental hygiene law, and, in other states, to those which are accredited by the joint  commission  as alcoholism or chemical dependence substance abuse treatment programs and are  similarly  licensed, certified or otherwise authorized in the state in which the facility is located.  (3) Coverage provided under this subsection may be subject  to  annual deductibles and co-insurance as deemed appropriate by the superintendent and  that  are  consistent with those imposed on other benefits within a given contract.  (3-a) A  contract  that  provides  large  group  coverage  under  this subsection  shall  not  impose  copayments or coinsurance for outpatient substance use disorder services that exceed the copayment or coinsurance imposed for a primary care office visit. Provided that no  greater  than one  such copayment may be imposed for all services provided in a single day by a facility licensed, certified or  otherwise  authorized  by  the office  of alcoholism and substance abuse services to provide outpatient substance use disorder services.  (4) A contract providing coverage for substance use disorder  services pursuant to this subsection shall provide up to twenty outpatient visits per  contract  or  calendar  year to an individual who identifies him or herself as a family member of a  person  suffering  from  substance  use disorder  and  who  seeks  treatment as a family member who is otherwise covered by the applicable contract  pursuant  to  this  subsection.  The coverage required by this subsection shall include treatment as a family member  pursuant  to  such  family  member's  own contract provided such family member:  (A) does not exceed the allowable number of family visits provided  by the applicable contract pursuant to this subsection; and  (B)  is otherwise entitled to coverage pursuant to this subsection and such family member's applicable contract.  (5)  This  paragraph  shall apply to facilities in this state that are licensed, certified or otherwise authorized by the office of  alcoholism and  substance abuse services for the provision of outpatient, intensive outpatient, outpatient rehabilitation  and  opioid  treatment  that  are participating  in  the corporation's provider network. Coverage provided under this subsection shall not be subject to preauthorization. Coverage provided under this subsection shall not be subject to concurrent review for the  first  four  weeks  of  continuous  treatment,  not  to  exceed twenty-eight  visits,  provided the facility notifies the corporation of both the start of treatment and the initial treatment  plan  within  two business  days.  The  facility  shall perform clinical assessment of the patient  at  each  visit,  including  periodic  consultation  with   the corporation  at  or  just  prior  to  the fourteenth day of treatment to ensure that the facility is using the evidence-based and  peer  reviewed clinical  review tool utilized by the corporation which is designated by the office of alcoholism and substance abuse services and appropriate to the age of the patient, to  ensure  that  the  outpatient  treatment  is medically  necessary  for  the  patient.  Any  utilization review of the treatment provided under this paragraph may  include  a  review  of  all services  provided  during  such  outpatient  treatment,  including  all services provided during the first four weeks of  continuous  treatment, not  to  exceed  twenty-eight  visits,  of  such  outpatient  treatment. Provided, however, the corporation shall  only  deny  coverage  for  any portion of the initial four weeks of continuous treatment, not to exceed twenty-eight  visits,  for  outpatient  treatment on the basis that such treatment was not medically necessary if such outpatient  treatment  was contrary  to  the  evidence-based and peer reviewed clinical review tool utilized by the  corporation  which  is  designated  by  the  office  of alcoholism and substance abuse services. A subscriber shall not have any financial  obligation  to  the  facility  for  any  treatment under this paragraph other than any copayment, coinsurance, or deductible otherwise required under the contract.  (6) The  criteria  for  medical  necessity  determinations  under  the contract  with  respect  to  outpatient  substance use disorder benefits shall be made available by the corporation to any  insured,  prospective insured, or in-network provider upon request.  (7) For purposes of this subsection:  (A)  "financial requirement" means deductible, copayments, coinsurance and out-of-pocket expenses;  (B) "predominant" means that  a  financial  requirement  or  treatment limitation  is  the  most  common  or  frequent of such type of limit or requirement.  (C) "treatment limitation" means limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or  duration  of  treatment  and  includes   nonquantitative   treatment limitations  such as: medical management standards limiting or excluding benefits based on medical necessity, or based on whether  the  treatment is  experimental  or  investigational; formulary design for prescription drugs;  network  tier  design;  standards  for  provider  admission   to participate  in  a  network,  including reimbursement rates; methods for determining usual, customary, and reasonable charges; fail-first or step therapy protocols; exclusions based on failure to complete a  course  of treatment; and restrictions based on geographic location, facility type, provider  specialty, and other criteria that limit the scope or duration of benefits for services provided under the contract; and  (D) "substance use disorder" shall have the meaning set forth  in  the most  recent  edition of the diagnostic and statistical manual of mental disorders or the most recent edition  of  another  generally  recognized independent   standard   of   current   medical  practice  such  as  the international classification of diseases.  (8)  A  corporation shall provide coverage under this subsection, at a minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. § 1185a).  (9) This paragraph shall apply to crisis stabilization centers in this state that are licensed pursuant to section 36.01 of the mental  hygiene law  and participate in the corporation's provider network. Benefits for care  in  a  crisis  stabilization  center  shall  not  be  subject   to preauthorization.  All  treatment  provided  under this paragraph may be reviewed retrospectively.  Where  care  is  denied  retrospectively,  an insured  shall not have any financial obligation to the facility for any treatment under this paragraph other than any copayment, coinsurance, or deductible otherwise required under the contract.  (l-1) (A) Every contract that  provides  medical,  major  medical,  or similar  comprehensive-type large group coverage shall provide immediate coverage for  all  buprenorphine  products,  methadone  or  long  acting injectable naltrexone without prior authorization for the detoxification or maintenance treatment of a substance use disorder.  (B)   Coverage  provided  under  this  paragraph  may  be  subject  to copayments, coinsurance, and annual deductibles that are consistent with those imposed on other benefits within the policy.  (m) A medical  expense  indemnity  corporation  or  a  health  service corporation  which  provides  coverage for any service within the lawful scope of practice of a duly licensed registered professional nurse  must make  available,  and  if  requested  by  all  subscribers  in  a  group remittance group, or by a  contract  holder  in  the  case  of  a  group contract  issued pursuant to section four thousand three hundred five of this chapter, provide reimbursement for such services when performed  by a  duly  licensed  registered professional nurse provided, however, that reimbursement shall not be made  for  nursing  services  provided  to  a subscriber  in a general hospital, nursing home, or a facility providing health  related  services,  as  such  terms  are  defined   in   section twenty-eight  hundred one of the public health law, or in a facility, as such term is defined in subdivision six of section 1.03  of  the  mental hygiene law, or in a physician's office. Such coverage may be subject to annual  deductibles and co-insurance as may be deemed appropriate by the superintendent and are consistent with those imposed on  other  benefits within  a  given  policy.  Such  coverage shall not replace, restrict or eliminate existing coverage provided by the  policy.  Coverage  for  the services  of  a  duly  licensed  registered  professional  nurse need be provided only if the  nature  of  the  patient's  illness  or  condition requires  nursing  care  which can appropriately be provided by a person with the education and professional skill of a  registered  professional nurse  and  the  nursing  care  is  necessary  in  the  treatment of the patient's illness or condition. Written notice of  the  availability  of such  coverage  shall be delivered to the group remitting agent or group contract holder  prior  to  inception  of  such  contract  and  annually thereafter, except that this notice shall not be required where a policy covers  two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are  employed in more than one state.  (n) In addition to the requirements of subsection (i) of this section, every  health service or medical expense indemnity corporation issuing a  group contract pursuant to this section or a group  remittance  contract for  delivery  in  this  state  which contract provides reimbursement to subscribers  or   physicians,   psychiatrists   or   psychologists   for psychiatric or psychological services or for the diagnosis and treatment of  mental  health  conditions,  however  defined in such contract, must provide the same coverage to persons covered under  the  group  contract for  such  services when performed by a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to subdivision two of section seven thousand seven hundred four  of  the education  law  and  in  addition  shall  have  either (i) three or more additional years experience in psychotherapy, which for the purposes  of this  subsection  shall  mean the use of verbal methods in interpersonal relationships with the intent of assisting a person or persons to modify attitudes and behavior which are intellectually, socially or emotionally maladaptive, under supervision, satisfactory  to  the  state  board  for social  work,  in a facility, licensed or incorporated by an appropriate governmental department, providing services for diagnosis  or  treatment of  mental  health  conditions,  or  (ii) three or more additional years experience in psychotherapy under the supervision, satisfactory  to  the state  board  for  social  work,  of  a  psychiatrist,  a  licensed  and registered psychologist or a licensed clinical social  worker  qualified for reimbursement pursuant to subsection (i) of this section, or (iii) a combination  of  the  experience  specified  in  paragraphs (i) and (ii) totaling three years, satisfactory to the state board for  social  work. The  state  board  for social work shall maintain a list of all licensed clinical  social  workers  qualified  for   reimbursement   under   this subsection.  (o)  A  hospital  service  corporation or a health service corporation which provides coverage for inpatient hospital care must make  available and, if requested by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contractholder in the  case  of  a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for  hospice  care. For  the  purposes  of this subsection, hospice care shall mean the care and treatment of a  covered  person  who  has  been  certified  by  such person's  primary attending physician as having a life expectancy of six months or less and which is provided by a hospice organization certified pursuant to article forty of the public health law or  under  a  similar certification  process  required  by  the  state  in  which  the hospice organization is located. Hospice care coverage shall be at  least  equal to:  (1)  a total of two hundred ten days of coverage beginning with the first day on which care is provided, for inpatient  hospice  care  in  a hospice  or in a hospital and home care and outpatient services provided by the hospice, including drugs  and  medical  supplies,  and  (2)  five visits  for  bereavement counseling services, either before or after the insured's death, provided to the family of the terminally  ill  insured. Such  coverage  shall  be  made  available  at  the inception of all new contracts and, with respect to contracts  issued  before  the  effective date of this provision, at the first annual anniversary date thereafter, without   evidence   of   insurability  and  at  any  subsequent  annual anniversary date subject to evidence of insurability. Such coverage  may be  subject  to  annual  deductibles  and  coinsurance  as may be deemed appropriate by the superintendent and are consistent with those  imposed on  other benefits within a given contract period. Written notice of the availability of such coverage shall be delivered to the group  remitting agent  or  group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or  more  employees  or  where  the  benefit  structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (p)  (1)  A  medical expense indemnity corporation, a hospital service corporation or a health service corporation that provides  coverage  for hospital,  surgical or medical care shall provide the following coverage for mammography screening for occult breast cancer:  (A) upon the recommendation of a physician, a mammogram, which may  be provided  by breast tomosynthesis, at any age for covered persons having a prior history of breast cancer or who have  a  first  degree  relative with a prior history of breast cancer;  (B)  a  single  baseline  mammogram,  which  may be provided by breast tomosynthesis, for covered persons aged thirty-five through thirty-nine, inclusive;  (C) an annual mammogram, which may be provided by breast tomosythesis, for covered persons aged forty and older;  (D) for large group contracts offered by a medical  expense  indemnity corporation,   a  hospital  service  corporation  or  a  health  service corporation that provide coverage  for  hospital,  surgical  or  medical care,  an  annual mammogram for covered persons aged thirty-five through thirty-nine, inclusive, upon the recommendation of a physician,  subject to  the  corporation's  determination  that  the  mammogram is medically necessary; and  (E) The coverage required in this paragraph or paragraph two  of  this subsection shall not be subject to annual deductibles or coinsurance.  (2)  For  purposes  of  paragraph  one of this subsection, mammography screening means an X-ray  examination  of  the  breast  using  dedicated equipment,  including  X-ray  tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less  than 0.5  rem  per  view  per  breast;  provided,  however,  that mammography screening shall also include breast tomosythesis.  (3) In addition to paragraph one or  two  of  this  subsection,  every contract  that provides coverage for hospital, surgical or medical care, except for a grandfathered health plan  under  paragraph  four  of  this subsection,   shall  provide  coverage  for  the  following  mammography screening services, and such coverage shall not  be  subject  to  annual deductibles or coinsurance:  (A)  evidence-based  items  or  services  for mammography that have in effect a rating of 'A' or 'B' in  the  current  recommendations  of  the United States preventive services task force; and  (B)  with  respect  to  women,  such  additional  preventive  care and screenings for mammography not described in  subparagraph  (A)  of  this paragraph  and  as provided for in comprehensive guidelines supported by the health resources and services administration.  (4) For purposes of this subsection, "grandfathered health plan" means coverage provided by a corporation in which an individual  was  enrolled on  March  twenty-third,  two  thousand  ten for as long as the coverage maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).  (5) Screening and diagnostic  imaging  for  the  detection  of  breast cancer, including diagnostic mammograms, breast ultrasounds, or magnetic resonance  imaging,  covered  under the contract shall not be subject to annual deductibles or coinsurance.  (q)  (1)  Every  policy  issued  by  a   medical   expense   indemnity corporation,   a  hospital  service  corporation  or  a  health  service corporation which provides coverage for prescribed drugs approved by the food and drug administration of the United  States  government  for  the treatment  of  certain types of cancer shall not exclude coverage of any such drug on the basis that  such  drug  has  been  prescribed  for  the  treatment  of  a type of cancer for which the drug has not been approved by the food and drug administration. Provided, however, that  such  drug must  be  recognized  for  treatment  of the specific type of cancer for which  the  drug has been prescribed in one of the following established reference compendia:  (i)  the  American   Hospital   Formulary   Service-Drug   Information (AHFS-DI);  (ii)  National  Comprehensive  Cancer  Networks  Drugs  and  Biologics Compendium;  (iii) Thomson Micromedex DrugDex;  (iv)  Elsevier  Gold  Standard's  Clinical  Pharmacology;   or   other authoritative compendia as identified by the Federal Secretary of Health and  Human  Services  or  the  Centers  for Medicare & Medicaid Services (CMS); or recommended by review article or editorial comment in a  major peer reviewed professional journal.  (2)  Notwithstanding the provisions of this subsection, coverage shall not be required for any experimental or  investigational  drugs  or  any drug  which  the  food  and  drug  administration  has  determined to be contraindicated for treatment of the specific type of cancer  for  which the  drug  has  been prescribed. The provisions of this subsection shall apply to cancer drugs only and nothing  herein  shall  be  construed  to create,  impair,  alter,  limit,  modify,  enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any  other  disease  or condition.  (q-1)  (1)  Every  contract  issued  by  a  medical  expense indemnity corporation,  a  hospital  service  corporation  or  a  health   service corporation  for  delivery  in  this  state that provides medical, major medical or similar comprehensive-type coverage and provides coverage for prescription drugs and for cancer chemotherapy treatment  shall  provide coverage for prescribed, orally administered anticancer medications used to  kill  or  slow  the  growth of cancerous cells. Such coverage may be subject to  co-pays,  coinsurance  or  deductibles,  provided  that  the co-pays,  coinsurance  or  deductibles  are  at least as favorable to an insured as  the  co-pays,  coinsurance  or  deductibles  that  apply  to coverage for intravenous or injected anticancer medications.  (2)  An  insurer  providing  coverage  under  this  paragraph  and any participating entity through which the insurer  offers  health  services shall not:  (A)  vary the terms of the contract for the purpose or with the effect of avoiding compliance with this paragraph;  (B) provide incentives (monetary or otherwise) to encourage a  covered person  to accept less than the minimum protections available under this paragraph;  (C) penalize in any way or reduce  or  limit  the  compensation  of  a health care practitioner for recommending or providing care to a covered person in accordance with this paragraph;  (D)  provide  incentives  (monetary  or  otherwise)  to  a health care practitioner  relating  to  the  services  provided  pursuant  to   this paragraph  intended  to  induce  or  have  the  effect  of inducing such practitioner  to  provide  care  to  a  covered  person  in   a   manner inconsistent with this paragraph; or  (E)  achieve compliance with this paragraph by imposing an increase in cost sharing for an intravenous or injected anticancer medication.  (r) Consistent with federal law, a hospital service corporation  or  a health  service corporation which provides coverage supplementing part A and part B of subchapter XVIII of the federal Social  Security  Act,  42 USC  §§ 1395 et seq., shall make available and, if requested by a person holding a direct payment individual contract or by all  persons  holding  individual  contracts  in a group whose premiums are paid by a remitting agent or by a contract holder in the case of  a  group  contract  issued pursuant  to  section  four thousand three hundred five of this article, provide  coverage  for at least ninety days of care in a nursing home as defined in section twenty-eight hundred one of the  public  health  law, except  when  such  coverage  would duplicate coverage that is available under the aforementioned subchapter XVIII. Such coverage shall  be  made available at the inception of all new contracts and, with respect to all other contracts at each anniversary date of the contract.  (1)  Coverage  shall  be subject to a copayment of twenty-five dollars per day.  (2) Brochures describing such coverage must be provided at the time of application for all new contracts and  thereafter  on  each  anniversary date  of  the contract, and with respect to all other contracts annually at each anniversary  date  of  the  contract.  Such  brochures  must  be approved  by the superintendent in consultation with the commissioner of health.   Such insurers shall report to the superintendent each year the  number of  contract holders to whom such insurers have issued such policies for nursing home coverage and the approximate number of persons  covered  by such policies.  (3)  The  commensurate  rate  for the coverage must be approved by the superintendent.   * (s) (1) A hospital service corporation or health service corporation which provides coverage for hospital care shall not exclude coverage for hospital  care  for  diagnosis  and  treatment  of  correctable  medical conditions  otherwise  covered  by the policy solely because the medical condition results in infertility; provided, however that:  (A) subject to the provisions of paragraph three of  this  subsection, in  no  case  shall such coverage exclude surgical or medical procedures provided as part of such hospital care which would correct malformation, disease or dysfunction resulting in infertility; and  (B) provided, further however,  that  subject  to  the  provisions  of paragraph  three  of  this  subsection,  in  no case shall such coverage exclude diagnostic  tests  and  procedures  provided  as  part  of  such hospital  care  that  are necessary to determine infertility or that are necessary in connection with  any  surgical  or  medical  treatments  or prescription   drug  coverage  provided  pursuant  to  this  subsection, including such diagnostic tests and procedures  as  hysterosalpingogram, hysteroscopy,  endometrial  biopsy,  laparoscopy, sono-hysterogram, post coital tests, testis biopsy, semen analysis, blood tests and ultrasound; and  (C) provided,  further  however,  every  such  policy  which  provides coverage  for  prescription  drugs  shall include, within such coverage, coverage for prescription drugs approved by the federal  Food  and  Drug Administration  for use in the diagnosis and treatment of infertility in accordance with paragraph three of this subsection.  (2) A medical expense indemnity or health  service  corporation  which provides  coverage  for  surgical  and  medical  care  shall not exclude coverage for surgical and medical care for diagnosis  and  treatment  of correctable  medical  conditions  otherwise covered by the policy solely because the medical condition results in infertility; provided,  however that:  (A)  subject  to the provisions of paragraph three of this subsection, in no case shall such coverage exclude surgical  or  medical  procedures which  would  correct  malformation, disease or dysfunction resulting in infertility; and  (B) provided, further however,  that  subject  to  the  provisions  of paragraph  three  of  this  subsection,  in  no case shall such coverage exclude diagnostic tests and procedures that are necessary to  determine infertility  or  that  are  necessary in connection with any surgical or medical  treatments  or  prescription drug coverage provided pursuant to this subsection, including  such  diagnostic  tests  and  procedures  as hysterosalpingogram,   hysteroscopy,  endometrial  biopsy,  laparoscopy, sono-hysterogram, post coital  tests,  testis  biopsy,  semen  analysis, blood tests and ultrasound; and  (C)  provided,  further  however,  every  such  policy  which provides coverage for prescription drugs shall  include,  within  such  coverage, coverage  for  prescription  drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility  in accordance with paragraph three of this subsection.  (3)   Coverage  of  diagnostic  and  treatment  procedures,  including prescription drugs used in the diagnosis and treatment of infertility as required by paragraphs one and two of this subsection shall be  provided in accordance with this paragraph.  (A) Diagnosis and treatment of infertility shall be prescribed as part of a physician's overall plan of care and consistent with the guidelines for coverage as referenced in this paragraph.  (B)   Coverage   may   be  subject  to  co-payments,  coinsurance  and deductibles as may be deemed appropriate by the  superintendent  and  as are  consistent with those established for other benefits within a given policy.  (C) Except as provided in subparagraphs (F) and (G) of this paragraph, coverage shall not be required to include the diagnosis and treatment of infertility in connection  with:  (i)  in  vitro  fertilization,  gamete intrafallopian  tube  transfers or zygote intrafallopian tube transfers; (ii)  the  reversal  of  elective  sterilizations;  (iii)   sex   change procedures;  (iv)  cloning;  or  (v)  medical  or  surgical  services or procedures that  are  deemed  to  be  experimental  in  accordance  with clinical guidelines referenced in subparagraph (D) of this paragraph.  (D)  The  superintendent,  in  consultation  with  the commissioner of health,  shall  promulgate  regulations  which   shall   stipulate   the guidelines  and  standards  which  shall  be  used  in  carrying out the provisions of this paragraph, which shall include:  (i) The identification of experimental procedures and  treatments  not covered  for  the  diagnosis  and treatment of infertility determined in accordance with the standards and guidelines established and adopted  by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine;  (ii) The identification of the required training, experience and other standards  for health care providers for the provision of procedures and treatments for the diagnosis and treatment of infertility determined  in accordance  with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine; and  (iii) The determination  of  appropriate  medical  candidates  by  the treating  physician  in  accordance  with  the  standards and guidelines established and adopted by the American  College  of  Obstetricians  and Gynecologists and/or the American Society for Reproductive Medicine.  (E)(i)  For  the  purposes  of  this subsection, "infertility" means a disease or condition  characterized  by  the  incapacity  to  impregnate another  person  or  to  conceive, defined by the failure to establish a clinical pregnancy after twelve months of  regular,  unprotected  sexual intercourse  or  therapeutic  donor insemination, or after six months of regular,   unprotected   sexual   intercourse   or   therapeutic   donor  insemination  for  a  female  thirty-five years of age or older. Earlier evaluation and treatment may  be  warranted  based  on  an  individual's medical history or physical findings.  (ii)  For  purposes of this subsection, "iatrogenic infertility" means an impairment of fertility by surgery, radiation, chemotherapy or  other medical treatment affecting reproductive organs or processes.  (F)  Coverage  shall  also  include  standard  fertility  preservation services when a medical  treatment  may  directly  or  indirectly  cause iatrogenic  infertility to an insured. Coverage may be subject to annual deductibles and coinsurance, including  copayments,  as  may  be  deemed appropriate  by  the  superintendent  and  as  are consistent with those established for other benefits within a given contract.  (G) Every large group contract that provides medical, major medical or similar comprehensive-type coverage shall  provide  coverage  for  three cycles  of  in-vitro fertilization used in the treatment of infertility. Coverage may be subject to annual deductibles and coinsurance, including copayments, as may be deemed appropriate by the  superintendent  and  as are  consistent with those established for other benefits within a given contract. For purposes of this subparagraph, a  "cycle"  is  defined  as either  all  treatment  that  starts  when:  preparatory medications are administered for ovarian  stimulation  for  oocyte  retrieval  with  the intent  of  undergoing  in-vitro  fertilization  using  a  fresh  embryo transfer; or medications are administered  for  endometrial  preparation with  the  intent  of  undergoing  in-vitro fertilization using a frozen embryo transfer.  (H) No corporation providing  coverage  under  this  subsection  shall discriminate  based  on an insured's expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life, or other health conditions, nor based on personal characteristics, including  age,  sex,  sexual  orientation,  marital  status  or  gender identity.  (4)  Every contract issued by a medical expense indemnity corporation, a hospital service corporation or a  health  services  corporation  that provides  coverage  for  prescription  fertility  drugs  and requires or permits  prescription  drugs  to  be   purchased   through   a   network participating  mail order or other non-retail pharmacy shall provide the same coverage for prescription  fertility  drugs  when  such  drugs  are purchased  from  a  network participating non-mail order retail pharmacy provided that the network participating non-mail order  retail  pharmacy agrees  in advance, through a contractual network agreement, to the same reimbursement  amount,  as  well  as  the  same  applicable  terms   and conditions,  that  the  corporation  has  established  for  the  network participating mail order or other non-retail pharmacy. In such case, the contract shall not impose any fee, co-payment, co-insurance,  deductible or  other condition on any covered person who does not elect to purchase prescription fertility drugs through a network participating mail  order or  other non-retail pharmacy; provided, however, that the provisions of this section shall not supersede the terms of  a  collective  bargaining agreement  or  apply  to  a  contract that is the result of a collective bargaining agreement between an employer and a recognized  or  certified employee organization.   * NB There are 2 sb (s)'s   * (s)  Notwithstanding any provision of a contract issued by a medical expense indemnity corporation, a dental expense indemnity corporation or health service corporation, every contract which provides  coverage  for care  provided  through  licensed  health professionals who can bill for services shall provide the same  coverage  and  reimbursement  for  such service  provided  pursuant  to  a  clinical  practice  plan established  pursuant to subdivision fourteen of  section  two  hundred  six  of  the public health law.   * NB There are 2 sb (s)'s  (t)  (1)  A  medical expense indemnity corporation, a hospital service corporation or a health service corporation that provides  coverage  for hospital, surgical, or medical care shall provide coverage for an annual cervical cytology screening for cervical cancer and its precursor states for  women  aged  eighteen  and  older.  Such  coverage required by this paragraph may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent  and  as  are  consistent  with those established for other benefits within a given contract.  (2)  For  purposes  of  paragraph  one  of  this  subsection, cervical cytology  screening  shall  include  an   annual   pelvic   examination, collection and preparation of a Pap smear, and laboratory and diagnostic services  provided  in  connection with examining and evaluating the Pap smear.  (3) In addition to paragraph one or  two  of  this  subsection,  every contract  that provides coverage for hospital, surgical or medical care, except for a grandfathered health plan  under  paragraph  four  of  this subsection,  shall  provide coverage for the following cervical cytology screening services, and such coverage shall not  be  subject  to  annual deductibles or coinsurance:  (A)  evidence-based  items or services for cervical cytology that have in effect a rating of 'A' or 'B' in the current recommendations  of  the United States preventive services task force; and  (B)  with  respect  to  women,  such  additional  preventive  care and screenings for cervical cytology not described in  subparagraph  (A)  of this paragraph and as provided for in comprehensive guidelines supported by the health resources and services administration.  (4) For purposes of this subsection, "grandfathered health plan" means coverage  provided  by a corporation in which an individual was enrolled on March twenty-third, two thousand ten for  as  long  as  the  coverage maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).  (u)  (1)  A  medical expense indemnity corporation or a health service corporation which provides medical coverage that includes  coverage  for physician  services  in  a  physician's  office  and  every policy which provides major medical  or  similar  comprehensive-type  coverage  shall include  coverage  for  the  following  equipment  and  supplies for the treatment of diabetes, if recommended or prescribed by  a  physician  or other  licensed  health  care  provider  legally authorized to prescribe under title eight of the education law: blood glucose monitors and blood glucose monitors for the visually  impaired,  data  management  systems, test  strips  for  glucose monitors and visual reading and urine testing strips, insulin, injection aids, cartridges for the  visually  impaired, syringes,  insulin  pumps  and  appurtenances  thereto, insulin infusion devices, and oral agents for controlling blood sugar. In  addition,  the commissioner  of the department of health shall provide and periodically update by rule or regulation a list of additional diabetes equipment and related supplies such as are medically necessary for  the  treatment  of diabetes,  for  which  there shall also be coverage. Such policies shall also include coverage for diabetes self-management education  to  ensure that persons with diabetes are educated as to the proper self-management and  treatment  of  their  diabetic  condition, including information on proper diets. Such coverage for self-management education and  education relating to diet shall be limited to visits medically necessary upon the diagnosis  of diabetes, where a physician diagnoses a significant change in the patient's symptoms or conditions which necessitate changes  in  a  patient's  self-management,  or where reeducation or refresher education is necessary. Such education may be provided by the physician  or  other licensed  health  care  provider  legally  authorized to prescribe under title  eight  of the education law, or their staff, as part of an office visit for diabetes diagnosis or treatment, or by  a  certified  diabetes nurse   educator,   certified   nutritionist,   certified  dietitian  or registered dietitian upon the referral of a physician or other  licensed health  care  provider legally authorized to prescribe under title eight of the education law. Education provided by the certified diabetes nurse educator, certified  nutritionist,  certified  dietitian  or  registered dietitian  may  be  limited  to  group  settings  wherever  practicable. Coverage for self-management education and education  relating  to  diet shall also include home visits when medically necessary.  (2) Such coverage may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with  those  established  for  other  benefits  within  a  given policy; provided however, the total amount that a covered person is required  to pay out of pocket for covered prescription insulin drugs shall be capped at  an  amount  not to exceed one hundred dollars per thirty-day supply, regardless of the amount or type of insulin needed to fill such  covered person's  prescription  and  regardless  of  the  insured's  deductible, copayment, coinsurance or any other cost sharing requirement.  (3) This subsection shall not apply to a policy which  covers  persons employed  in  more  than one state or the benefit structure of which was the subject of collective bargaining affecting persons employed in  more than  one  state  unless  such policy is issued under the New York state health insurance plan established under  article  eleven  of  the  civil service law or issued to or through a local government.  (u-1)  A  medical  expense  indemnity  corporation or a health service corporation which provides medical coverage that includes  coverage  for physician  services  in  a  physician's  office  and  every policy which provides major medical  or  similar  comprehensive-type  coverage  shall include  coverage  for  equipment and supplies used for the treatment of ostomies, if prescribed by a physician or  other  licensed  health  care provider  legally  authorized  to  prescribe  under  title  eight of the education law. Such coverage shall be subject to annual deductibles  and coinsurance  as  deemed  appropriate by the superintendent. The coverage required by this subsection shall be identical to, and shall not enhance or increase the coverage required as part of essential  health  benefits as  defined  in  subsection  (a)  of section four thousand three hundred six-h of this article.  (v)  (1)  Every  contract  issued  by  a  medical  expense   indemnity corporation,  hospital service corporation or health service corporation which provides coverage for inpatient hospital care shall  provide  such coverage  for such period as is determined by the attending physician in consultation with the patient to be  medically  appropriate  after  such covered person has undergone a lymph node dissection or a lumpectomy for the  treatment of breast cancer or a mastectomy covered by the contract. Such coverage may be subject to annual deductibles  and  coinsurance  as may  be  deemed  appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. Written notice of the availability of such coverage shall be  delivered  to  the group remitting agent or group contract holder prior to the inception of such contract and annually thereafter.  (2)   A   medical  expense  indemnity  corporation,  hospital  service corporation or health service corporation which provides coverage  under this  subsection  and any participating entity through which the insurer offers health services shall not:  (A) deny to a covered person eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the contract or vary  the terms  of  the  contract  for the purpose or with the effect of avoiding compliance with this subsection;  (B)  provide incentives (monetary or otherwise) to encourage a covered person to accept less than the minimum protections available under  this subsection;  (C)  penalize  in  any  way  or  reduce or limit the compensation of a health care practitioner for recommending or providing care to a covered person in accordance with this subsection;  (D) provide incentives  (monetary  or  otherwise)  to  a  health  care practitioner   relating  to  the  services  provided  pursuant  to  this subsection intended to induce  or  have  the  effect  of  inducing  such practitioner   to   provide  care  to  a  covered  person  in  a  manner inconsistent with this subsection; or  (E) restrict coverage for any portion of a period  within  a  hospital length  of  stay  required  under  this  subsection in a manner which is inconsistent with the coverage provided for  any  preceding  portion  of such stay.  (3)  The  prohibitions in paragraph two of this subsection shall be in addition to the provisions  of  sections  four  thousand  three  hundred seventeen  and  four thousand three hundred eighteen of this article and nothing in this paragraph shall  be  construed  to  suspend,  supersede, amend or otherwise modify such sections.  (w)(1)   Every   contract   issued  by  a  medical  expense  indemnity corporation or health service corporation which provides medical,  major medical,  or  similar  comprehensive-type coverage must provide coverage for a second medical opinion by an appropriate specialist, including but not limited to a specialist affiliated with a specialty care center  for the  treatment  of  cancer,  in  the  event  of  a  positive or negative diagnosis of cancer or a recurrence of cancer or a recommendation  of  a course of treatment for cancer, subject to the following:  (i)  In  the  case  of a contract that requires, or provides financial incentives for, the covered person  to  receive  covered  services  from health  care providers participating in a provider network maintained by or under contract with  the  corporation,  the  contract  shall  include coverage   for   a  second  medical  opinion  from  a  non-participating specialist, including but not limited to a specialist affiliated with  a specialty  care  center  for the treatment of cancer, when the attending physician provides a written referral to a non-participating specialist, at no additional cost to the covered person  beyond  what  such  covered person  would  have  paid  for services from a participating appropriate specialist. Provided  however  that  nothing  herein  shall  impair  the covered person's rights (if any) under the contract to obtain the second medical  opinion  from  a non-participating specialist without a written referral, subject to the payment  of  additional  coinsurance  (if  any) required  by  the  contract  for  services provided by non-participating providers.  The  corporation  shall  compensate  the   non-participating specialist  at  the  usual,  customary and reasonable rate, or at a rate listed on a fee schedule filed and approved by the superintendent  which provides a comparable level of reimbursement.  (ii)  In  the  case  of  a  contract  that  does not provide financial incentives for, and does not require,  the  covered  person  to  receive covered  services from health care providers participating in a provider network maintained by  or  under  contract  with  the  corporation,  the contract  shall  include  coverage  for  a second medical opinion from a specialist at no additional cost to the covered person beyond  what  the  covered person would have paid for comparable services covered under the contract.  (iii)   Such  coverage  may  be  subject  to  annual  deductibles  and coinsurance as may be deemed appropriate by the  superintendent  and  as are  consistent with those established for other benefits within a given contract and,  where  applicable,  consistent  with  the  provisions  of subparagraphs (i) and (ii) of this paragraph.   Nothing   in   this   subsection   shall  eliminate  or  diminish  the corporation's obligation to comply with the provisions of  section  four thousand  eight  hundred  four  of  this  chapter and section forty-four hundred three of the public health law where applicable. Written  notice of  the  availability  of  such coverage shall be delivered to the group remitting agent or group contract holder prior to the inception of  such contract and annually thereafter.  (2)   A  medical  expense  indemnity  corporation  or  health  service corporation which  provides  coverage  under  this  subsection  and  any participating  entity  through  which the insurer offers health services shall not:  (A) deny to a covered person eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the contract or vary  the terms  of  the  contract  for the purpose or with the effect of avoiding compliance with this subsection;  (B) provide incentives (monetary or otherwise) to encourage a  covered person  to accept less than the minimum protections available under this subsection;  (C) penalize in any way or reduce  or  limit  the  compensation  of  a health care practitioner for recommending or providing care to a covered person in accordance with this subsection; or  (D)  provide  incentives  (monetary  or  otherwise)  to  a health care practitioner  relating  to  the  services  provided  pursuant  to   this subsection  intended  to  induce  or  have  the  effect of inducing such practitioner  to  provide  care  to  a  covered  person  in   a   manner inconsistent with this subsection.  (3)  The  prohibitions in paragraph two of this subsection shall be in addition to the provisions  of  sections  four  thousand  three  hundred seventeen  and  four thousand three hundred eighteen of this article and nothing in this paragraph shall  be  construed  to  suspend,  supersede, amend or otherwise modify such sections.  (x)(1)   Every   contract   issued  by  a  medical  expense  indemnity corporation, hospital service corporation or health service  corporation which  provides  coverage for surgical or medical care shall provide the following coverage for breast reconstruction surgery after a  mastectomy or partial mastectomy:  (A) all stages of reconstruction of the breast on which the mastectomy or partial mastectomy has been performed; and  (B)  surgery  and  reconstruction  of  the  other  breast to produce a symmetrical appearance; in the manner determined by the attending physician and the  patient  to be  appropriate.  Such  coverage may be subject to annual deductibles or coinsurance  provisions  as   may   be   deemed   appropriate   by   the superintendent  and  as  are consistent with those established for other benefits within a given policy. Written notice of  the  availability  of such  coverage  shall be delivered to the group remitting agent or group contract holder prior to the inception of  such  contract  and  annually thereafter.  (2)   A   medical  expense  indemnity  corporation,  hospital  service corporation or health service corporation which provides coverage  under  this  subsection  and any participating entity through which the insurer offers health services shall not:  (A) deny to a covered person eligibility, or continued eligibility, to enroll  or  to  renew coverage under the terms of the policy or vary the terms of the policy for the purpose  or  with  the  effect  of  avoiding compliance with this subsection;  (B)  provide incentives (monetary or otherwise) to encourage a covered person to accept less than the minimum protections available under  this subsection;  (C)  penalize  in  any  way  or  reduce or limit the compensation of a health care practitioner for recommending or providing care to a covered person in accordance with this subsection;  (D) provide incentives  (monetary  or  otherwise)  to  a  health  care practitioner   relating  to  the  services  provided  pursuant  to  this subsection intended to induce  or  have  the  affect  of  inducing  such practitioner   to   provide  care  to  a  covered  person  in  a  manner inconsistent with this subsection;  (E) restrict coverage for any portion of a period  within  a  hospital length  of  stay  required  under  this  subsection in a manner which is inconsistent with the coverage provided for  any  preceding  portion  of such stay; or  (F)  the  prohibitions  in  this paragraph shall be in addition to the provisions of sections four thousand three hundred  seventeen  and  four thousand  three  hundred  eighteen  of  this article and nothing in this paragraph shall be construed to suspend, supersede, amend  or  otherwise modify such sections.   * (y)  Every  contract  that  provides coverage for prescription drugs shall include coverage for the cost of enteral formulas  for  home  use, whether  administered  orally or via tube feeding, for which a physician or other licensed health care provider legally authorized  to  prescribe under  title eight of the education law has issued a written order. Such written order shall state that the enteral formula is clearly  medically necessary  and has been proven effective as a disease-specific treatment regimen. Specific diseases and disorders for which enteral formulas have been proven effective shall include, but are not limited  to,  inherited diseases  of  amino-acid  or  organic  acid metabolism; Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal motility such  as chronic   intestinal   pseudo-obstruction;  and  multiple,  severe  food allergies  including,  but  not  limited   to   immunoglobulin   E   and nonimmunoglobulin E-mediated allergies to multiple food proteins; severe food protein induced enterocolitis syndrome; eosinophilic disorders; and impaired  absorption  of  nutrients  caused  by  disorders affecting the absorptive   surface,   function,   length,   and   motility   of    the gastrointestinal  tract.  Enteral  formulas that are medically necessary and taken under written order from a  physician  for  the  treatment  of specific  diseases  shall  be distinguished from nutritional supplements taken electively. Coverage for certain inherited diseases of amino  acid and   organic  acid  metabolism  as  well  as  severe  protein  allergic conditions shall include modified  solid  food  products  that  are  low protein,  contain  modified  protein,  or  are amino acid based that are medically necessary.   * NB There are 2 sb§ (y)'s   * (y)(1) Every contract issued by a health service  corporation  or  a medical  expense indemnity corporation which is a "managed care product" as defined in paragraph four of this subsection that  includes  coverage for  physician services in a physician's office, and every "managed care product" that  provides  major  medical  or  similar  comprehensive-type coverage,  shall  include  coverage for chiropractic care, as defined in  section six thousand  five  hundred  fifty-one  of  the  education  law, provided  by  a  doctor of chiropractic licensed pursuant to article one hundred  thirty-two  of  the  education  law,  in  connection  with  the detection  or  correction  by  manual  or mechanical means of structural imbalance, distortion or subluxation in the human body for  the  purpose of  removing  nerve  interference,  and  the effects thereof, where such interference is the result of or related to distortion, misalignment  or subluxation  of  or  in the vertebral column. However, chiropractic care and services may be subject to  reasonable  deductible,  co-payment  and co-insurance  amounts,  reasonable fee or benefit limits, and reasonable utilization review, provided that any such amounts, limits  and  review: (a)  shall  not  function to direct treatment in a manner discriminative against chiropractic care, and (b) individually and  collectively  shall be  no  more  restrictive than those applicable under the same policy to care  or  services  provided  by  other  health  professionals  in   the diagnosis,  treatment  and management of the same or similar conditions, injuries,  complaints,  disorders  or  ailments,   even   if   differing nomenclature  is  used  to  describe  the  condition, injury, complaint, disorder or ailment. Nothing herein  contained  shall  be  construed  as impeding  or preventing either the provision or coverage of chiropractic care and services by duly licensed doctors of chiropractic,  within  the lawful scope of chiropractic practice, in hospital facilities on a staff or employee basis.  (3) Every contract issued by a health service corporation or a medical expense  indemnity  corporation  which  includes  coverage for physician services in a physician's office,  and  every  contract  which  provides major  medical  or  similar  comprehensive-type  coverage,  other than a "managed care product" as defined in paragraph four of this  subsection, shall  provide coverage for chiropractic care, as defined in section six thousand five hundred fifty-one of the  education  law,  provided  by  a doctor   of  chiropractic  licensed  pursuant  to  article  one  hundred thirty-two of the education law, in connection  with  the  detection  or correction  by  manual  or  mechanical  means  of  structural imbalance, distortion or subluxation in the human body for the purpose of  removing nerve  interference, and the effects thereof, where such interference is the result of or related to distortion, misalignment or  subluxation  of or  in the vertebral column. However, chiropractic care and services may be  subject  to  reasonable  deductible,  co-payment  and   co-insurance amounts,  reasonable  fee  or benefit limits, and reasonable utilization review, provided that any such amounts, limits and review:  (a)  shall not  function  to  direct  treatment  in a manner discriminative against chiropractic care, and (b) individually and  collectively  shall  be  no more  restrictive  than those applicable under the same contract to care or services provided by other health  professionals  in  the  diagnosis, treatment  and  management  of the same or similar conditions, injuries, complaints, disorders or ailments even if differing nomenclature is used to describe the  condition,  injury,  complaint,  disorder  or  ailment. Nothing  herein  contained  shall be construed as impeding or preventing either the provision or coverage of chiropractic care  and  services  by duly  licensed  doctors  of  chiropractic,  within  the  lawful scope of chiropractic practice, in hospital facilities on  a  staff  or  employee basis.  (4)  For  purposes  of this subsection, a "managed care product" shall mean a contract  which  requires  that  medical  or  other  health  care services covered under the contract, other than emergency care services, be provided by, or pursuant to a referral from, a primary care provider, and  that services provided pursuant to such a referral be rendered by a health care provider participating in  the  corporation's  managed  care  provider  network.  In  addition, a managed care product shall also mean the in-network portion of a contract  which  requires  that  medical  or other  health  care  services  covered  under  the  contract, other than emergency care services, be provided by, or pursuant to a referral from, a  primary  care provider, and that services provided pursuant to such a referral be rendered by a health  care  provider  participating  in  the corporation's managed care provider network, in order for the insured to be entitled to the maximum reimbursement under the contract.  (5)  The coverage required by this subsection shall not be abridged by any regulation promulgated by the superintendent.   * NB There are 2 sb§ (y)'s  (z) No contract issued by a medical expense indemnity  corporation,  a hospital  service  corporation  or  a  health  service corporation shall exclude coverage of a health care service, as defined in  paragraph  two of subsection (e) of section four thousand nine hundred of this chapter, rendered or proposed to be rendered to an insured on the basis that such service  is  experimental  or  investigational, is rendered as part of a clinical trial as defined in  subsection  (b-2)  of  section  forty-nine hundred   of  this  chapter,  or  a  prescribed  pharmaceutical  product referenced in subparagraph (B) of paragraph two  of  subsection  (e)  of section forty-nine hundred of this chapter provided that coverage of the patient costs of such service has been recommended for the insured by an external  appeal agent upon an appeal conducted pursuant to subparagraph (B) of paragraph four of subsection (b) of section  four  thousand  nine hundred  fourteen  of  this  chapter.  The determination of the external appeal agent shall be binding on  the  parties.  For  purposes  of  this paragraph,  patient  costs  shall have the same meaning as such term has for purposes of subparagraph (B) of paragraph four of subsection (b)  of section  four  thousand nine hundred fourteen of this chapter; provided, however, that coverage for the services required under  this  subsection shall  be  provided  subject  to  the  terms  and  conditions  generally applicable to other benefits provided under the policy.  (z-1) (1) Every policy delivered or issued for delivery in this  state which  provides  medical  coverage  that includes coverage for physician services in a physician's office and every policy which  provides  major medical  or  similar comprehensive-type coverage shall provide, upon the prescription of a health care provider legally authorized  to  prescribe under  title  eight  of  the  education  law, the following coverage for diagnostic screening for prostatic cancer:  (A) standard diagnostic testing  including,  but  not  limited  to,  a digital  rectal  examination and a prostate-specific antigen test at any age for men having a prior history of prostate cancer; and  (B) an annual  standard  diagnostic  examination  including,  but  not limited to, a digital rectal examination and a prostate-specific antigen test  for  men  age  fifty and over who are asymptomatic and for men age forty and over with  a  family  history  of  prostate  cancer  or  other prostate cancer risk factors.  (2)  Such  coverage  shall  not  be  subject  to annual deductibles or coinsurance.  (aa)(1) Every contract issued by a hospital service company or  health service   corporation   which   provides   major   medical   or  similar comprehensive-type  coverage  shall  include  coverage  for  prehospital emergency  medical  services for the treatment of an emergency condition when such services  are  provided  by  an  ambulance  service  issued  a certificate  to  operate  pursuant to section three thousand five of the public health law.  (2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant  to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services  provided  pursuant  to this subsection, except for the collection of copayments, coinsurance or deductibles  for which the insured is responsible for under the terms of the policy.  (3)  An  insurer  shall  provide  reimbursement  for  those   services prescribed  by  this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon  rates,  an insurer  shall  pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.  (4) The provisions of this subsection shall  have  no  application  to transfers  of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection.  (5) As used in this subsection:  (A)  "Prehospital  emergency  medical  services"  means   the   prompt evaluation  and  treatment  of  an  emergency  medical condition, and/or non-air-borne transportation of the  patient  to  a  hospital;  provided however,    where   the   patient   utilizes   non-air-borne   emergency transportation pursuant to this subsection, reimbursement shall be based on whether a prudent  layperson,  possessing  an  average  knowledge  of medicine  and  health,  could  reasonably  expect  the  absence  of such transportation to result  in  (i)  placing  the  health  of  the  person afflicted  with  such condition in serious jeopardy, or in the case of a behavioral condition placing the health of  such  person  or  others  in serious  jeopardy;  (ii)  serious  impairment  to  such  person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; (iv) serious disfigurement of such person; or  (v)  a  condition described  in  clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the Social Security Act.  (B) "Emergency condition" means a medical or behavioral condition that manifests itself by acute symptoms  of  sufficient  severity,  including severe  pain,  such  that  a  prudent  layperson,  possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (i) placing the health  of  the person afflicted with such condition in serious jeopardy, or in the case of  a  behavioral condition, placing the health of such person or others in serious jeopardy; (ii) serious impairment  to  such  person's  bodily functions; (iii) serious dysfunction of any bodily organ or part of such person;  (iv)  serious  disfigurement of such person; or (v) a condition described in clause (i), (ii) or (iii) of section 1867(e)(1)(A)  of  the Social Security Act.  (bb)  A  health  service  corporation  or  a  medical  service expense indemnity  corporation  that   provides   major   medical   or   similar comprehensive-type coverage shall provide such coverage for bone mineral density  measurements  or tests, and if such contract otherwise includes coverage for prescription drugs,  drugs  and  devices  approved  by  the federal  food and drug administration or generic equivalents as approved substitutes. In determining appropriate coverage provided by  paragraphs one, two and three of this subsection, the insurer or health maintenance organization  shall  adopt  standards  that  include the criteria of the federal Medicare program and the criteria of the national institutes  of health  for  the  detection of osteoporosis, provided that such coverage shall be further determined as follows:  (1) For purposes of paragraphs two and three of this subsection,  bone mineral  density  measurements or tests, drugs and devices shall include those covered under the criteria of the federal Medicare program as well as those in accordance with the criteria of the national  institutes  of  health,  including,  as consistent with such criteria, dual-energy x-ray absorptiometry.  (2)  For purposes of paragraphs one and three of this subsection, bone mineral density measurements  or  tests,  drugs  and  devices  shall  be covered  for  individuals  meeting the criteria for coverage, consistent with the criteria under the federal Medicare program or the criteria  of the  national  institutes  of  health;  provided  that,  to  the  extent consistent with  such  criteria,  individuals  qualifying  for  coverage shall, at a minimum, include individuals:  (i)  previously  diagnosed  as  having osteoporosis or having a family history of osteoporosis; or  (ii) with symptoms or conditions indicative of the  presence,  or  the significant risk, of osteoporosis; or  (iii)  on  a  prescribed  drug  regimen  posing  a significant risk of osteoporosis; or  (iv) with lifestyle factors to such a degree as posing  a  significant risk of osteoporosis; or  (v)  with  such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis.  (3) Such coverage required pursuant to paragraph one or  two  of  this subsection  may  be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are  consistent  with those established for other benefits within a given policy.  (4)  In  addition  to  paragraph one, two or three of this subsection, every  contract  that  provides  hospital,  surgical  or  medical   care coverage, except for a grandfathered health plan under paragraph five of this  subsection,  shall  provide  coverage  for  the following items or services for bone mineral  density,  and  such  coverage  shall  not  be subject to annual deductibles or coinsurance:  (A)  evidence-based  items  or  services for bone mineral density that have in effect a rating of 'A' or 'B' in the current recommendations  of the United States preventive services task force; and  (B)  with  respect  to  women,  such  additional  preventive  care and screenings for bone mineral density not described in subparagraph (A) of this paragraph and as provided for in comprehensive guidelines supported by the health resources and services administration.  (5) For purposes of this subsection, "grandfathered health plan" means coverage provided by a corporation in which an individual  was  enrolled on  March  twenty-third,  two  thousand  ten for as long as the coverage maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).  (cc) (1) Every contract  that  provides  medical,  major  medical,  or similar  comprehensive  type  coverage that is issued, amended, renewed, effective or delivered on or after January first, two  thousand  twenty, shall   provide   coverage   for  all  of  the  following  services  and contraceptive methods:  (A) All FDA-approved contraceptive drugs, devices, and other products. This includes all  FDA-approved  over-the-counter  contraceptive  drugs, devices,  and  products  as  prescribed or as otherwise authorized under state or federal law. The following applies to this coverage:  (i)  where  the  FDA  has  approved  one  or  more   therapeutic   and pharmaceutical  equivalent,  as  defined  by  the  FDA,  versions  of  a contraceptive drug, device, or product, a contract is  not  required  to include  all  such therapeutic and pharmaceutical equivalent versions in its formulary, so long as at least one is included and  covered  without cost-sharing and in accordance with this subsection;  (ii) if the covered therapeutic and pharmaceutical equivalent versions of  a drug, device, or product are not available or are deemed medically  inadvisable  a  contract  shall  provide  coverage  for   an   alternate therapeutic  and  pharmaceutical equivalent version of the contraceptive drug, device, or product without cost-sharing. If the  attending  health care   provider,   in  his  or  her  reasonable  professional  judgment, determines that the use of a non-covered therapeutic  or  pharmaceutical equivalent  of  a drug, device, or product is warranted, the health care provider's  determination  shall  be  final.  The  superintendent  shall promulgate regulations establishing a process, including timeframes, for an  insured,  an insured's designee or an insured's health care provider to request coverage of a  non-covered  contraceptive  drug,  device,  or product.  Such regulations shall include a requirement that insurers use an  exception  form  that  shall  meet  criteria  established   by   the superintendent;  (iii)  this  coverage  shall  include  emergency contraception without cost-sharing when provided pursuant to a  prescription  or  order  under section  sixty-eight  hundred  thirty-one  of  the education law or when lawfully provided over the counter; and  (iv) this coverage must allow for  the  dispensing  of  up  to  twelve months worth of a contraceptive at one time;  (B) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and identified  in  the  comprehensive  guidelines  supported  by the health resources and services administration and thereby  incorporated  in  the essential health benefits benchmark plan;  (C) Patient education and counseling on contraception; and  (D)  Follow-up  services  related to the drugs, devices, products, and procedures covered under this subsection, including, but not limited to, management of side effects,  counseling  for  continued  adherence,  and device insertion and removal.  (2)  A  contract  subject  to  this  subsection  shall  not  impose  a deductible,  coinsurance,   copayment,   or   any   other   cost-sharing requirement on the coverage provided pursuant to this subsection.  (3)  Except  as otherwise authorized under this subsection, a contract shall not impose any restrictions or delays  on  the  coverage  required under this subsection.  (4)  Benefits  for an enrollee under this subsection shall be the same for an  enrollee's  covered  spouse  or  domestic  partner  and  covered nonspouse dependents.  (5)   Notwithstanding  any  other  provision  of  this  subsection,  a religious employer may request a contract without coverage  for  federal food  and  drug  administration  approved contraceptive methods that are contrary to the religious employer's religious tenets. If so  requested, such  contract  shall  be  provided  without  coverage for contraceptive methods.  This paragraph shall not be  construed  to  deny  an  enrollee coverage of, and timely access to, contraceptive methods.  (A)  For  purposes  of  this  subsection, a "religious employer" is an entity for which each of the following is true:  (i) The inculcation of religious values is the purpose of the entity.  (ii) The entity primarily employs  persons  who  share  the  religious tenets of the entity.  (iii)  The  entity  serves  primarily  persons who share the religious tenets of the entity.  (iv) The entity is a nonprofit organization as  described  in  Section 6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.  (B) Every religious employer that invokes the exemption provided under this  paragraph  shall  provide  written notice to prospective enrollees prior to enrollment with the plan, listing the contraceptive health care services the employer refuses to cover for religious reasons.  (6) (A) Where a group contractholder makes an election not to purchase coverage for contraceptive drugs or devices in accordance with paragraph five of this subsection, each enrollee covered under the contract issued to that group contractholder shall have the right to  directly  purchase the  rider  required  by  this  subsection  from  the  insurer or health maintenance  organization  which  issued  the  group  contract  at   the prevailing  small group community rate for such rider whether or not the employee is part of a small group.  (B) Where a group contractholder makes an  election  not  to  purchase coverage for contraceptive drugs or devices in accordance with paragraph five  of this subsection, the insurer or health maintenance organization that provides such coverage shall provide written  notice  to  enrollees upon  enrollment  with the insurer or health maintenance organization of their right to directly purchase a rider for coverage for  the  cost  of contraceptive  drugs  or  devices.  The  notice  shall  also  advise the enrollees of the additional premium for such coverage.  (7) Nothing in this subsection shall be  construed  as  authorizing  a contract  which  provides  coverage  for  prescription  drugs to exclude coverage for  prescription  drugs  prescribed  for  reasons  other  than contraceptive purposes.  (8)   For   the   purposes   of   this   paragraph,  "over-the-counter contraceptive products"  shall  mean  those  products  provided  for  in comprehensive  guidelines supported by the health resources and services administration as of January twenty-first, two thousand nineteen.  (dd)  No  health  service  corporation  or  medical  service   expense indemnity  corporation  which provides medical, major medical or similar comprehensive-type coverage shall exclude coverage for services  covered under  such  policy  when  provided  by  a comprehensive care center for eating disorders pursuant to article thirty of the mental  hygiene  law; provided,  however,  that reimbursement by such corporation for services provided through such comprehensive care centers shall,  to  the  extent possible  and  practicable,  be structured in a manner to facilitate the individualized, comprehensive and integrated plans of  care  which  such centers' network of practitioners and providers are required to provide.  (ee)  (1)  A medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage  for hospital  or  surgical  care  coverage  shall  not  exclude coverage for screening, diagnosis  and  treatment  of  medical  conditions  otherwise covered  by  the  contract  solely  because the treatment is provided to diagnose or treat autism spectrum disorder.  (2) Every contract that provides physician  services,  medical,  major medical  or  similar  comprehensive-type coverage shall provide coverage for the screening, diagnosis and treatment of autism  spectrum  disorder in accordance with this paragraph and shall not exclude coverage for the screening,  diagnosis  or  treatment  of  medical  conditions  otherwise covered by the contract because the individual is diagnosed with  autism spectrum  disorder.  Such coverage may be subject to annual deductibles, copayments  and  coinsurance  as  may  be  deemed  appropriate  by   the superintendent  and  shall  be  consistent  with  those imposed on other benefits under the contract. This paragraph shall not  be  construed  as limiting  the  benefits  that  are  otherwise available to an individual under the contract,  provided  however  that  such  contract  shall  not contain  any  limitations  on  visits  that  are  solely  applied to the treatment of  autism  spectrum  disorder.  No  insurer  shall  terminate coverage  or  refuse to deliver, execute, issue, amend, adjust, or renew coverage to an individual solely because  the  individual  is  diagnosed with  autism  spectrum  disorder  or  has  received treatment for autism spectrum disorder. Coverage shall be subject to utilization  review  and  external  appeals of health care services pursuant to article forty-nine of this chapter as well  as  case  management  and  other  managed  care provisions.  (3) For purposes of this subsection:  (A)  "autism  spectrum  disorder"  means  any  pervasive developmental disorder as defined in the most recent edition  of  the  diagnostic  and statistical manual of mental disorders.  (B)  "applied behavior analysis" means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli  and consequences,  to  produce  socially  significant  improvement  in human behavior, including the use  of  direct  observation,  measurement,  and functional   analysis   of  the  relationship  between  environment  and behavior.  (C) "behavioral  health  treatment"  means  counseling  and  treatment programs,  when  provided  by  a licensed provider, and applied behavior analysis, when provided by a  person  that  is  licensed,  certified  or otherwise  authorized  to  provide  applied  behavior analysis, that are necessary to develop,  maintain,  or  restore,  to  the  maximum  extent practicable, the functioning of an individual.  (D)   "diagnosis  of  autism  spectrum  disorder"  means  assessments, evaluations, or tests to  diagnose  whether  an  individual  has  autism spectrum disorder.  (E)  "pharmacy care" means medications prescribed by a licensed health care provider legally authorized to prescribe under title eight  of  the education law.  (F)  "psychiatric care" means direct or consultative services provided by a psychiatrist licensed  in  the  state  in  which  the  psychiatrist practices.  (G)   "psychological  care"  means  direct  or  consultative  services provided  by  a  psychologist  licensed  in  the  state  in  which   the psychologist practices.  (H)   "therapeutic  care"  means  services  provided  by  licensed  or certified speech therapists, occupational therapists, social workers, or physical therapists.  (I)  "treatment  of  autism  spectrum  disorder"  shall  include   the following care and assistive communication devices prescribed or ordered for  an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist:  (i) behavioral health treatment;  (ii) psychiatric care;  (iii) psychological care;  (iv) medical care provided by a licensed health care provider;  (v) therapeutic care,  including  therapeutic  care  which  is  deemed habilitative  or  nonrestorative,  in the event that the policy provides coverage for therapeutic care; and  (vi) pharmacy care in the event that the  contract  provides  coverage for prescription drugs.  (4)  Coverage  may be denied on the basis that such treatment is being provided to the covered person pursuant to an  individualized  education plan  under  article  eighty-nine of the education law. The provision of services pursuant to an individualized family service plan under section twenty-five  hundred  forty-five  of   the   public   health   law,   an individualized education plan under article eighty-nine of the education law,  or  an  individualized service plan pursuant to regulations of the office for persons with  developmental  disabilities  shall  not  affect coverage  under the policy for services provided on a supplemental basis outside of an educational setting if such services are prescribed  by  a licensed physician or licensed psychologist.  (5)  Nothing  in  this  subsection  shall  be  construed to affect any obligation to provide services to an individual under an  individualized family  service plan under section twenty-five hundred forty-five of the public health  law,  an  individualized  education  plan  under  article eighty-nine  of  the  education  law,  or an individualized service plan pursuant to regulations of the office  for  persons  with  developmental disabilities.  (6)  Nothing  in  this  subsection  shall  be  construed to affect any obligation to provide coverage for otherwise-covered services solely  on the  basis  that  the  services  constitute  early  intervention program services pursuant to section three thousand two hundred thirty-five-a of this article or an individualized service plan pursuant  to  regulations of the office for persons with developmental disabilities.  (7)  Nothing  in  this  subsection  shall  be  construed  to prevent a contract from providing services  through  a  network  of  participating providers   who  shall  meet  certain  requirements  for  participation, including provider credentialing.  (8)  Coverage  under  this  subsection  shall  not   apply   financial requirements  or  treatment  limitations  to  autism  spectrum  disorder benefits that  are  more  restrictive  than  the  predominant  financial requirements  and  treatment  limitations  applied  to substantially all medical and surgical benefits covered by the policy.  (9) The  criteria  for  medical  necessity  determinations  under  the contract with respect to autism spectrum disorder benefits shall be made available  by  the  corporation  to any insured, prospective insured, or in-network provider upon request.  (10) For purposes of this subsection:  (A) "financial requirement" means deductible, copayments,  coinsurance and out-of-pocket expenses;  (B)  "predominant"  means  that  a  financial requirement or treatment limitation is the most common or frequent  of  such  type  of  limit  or requirement; and  (C) "treatment limitation" means limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or   duration   of  treatment  and  includes  nonquantitative  treatment limitations such as: medical management standards limiting or  excluding benefits  based  on medical necessity, or based on whether the treatment is experimental or investigational; formulary  design  for  prescription drugs;   network  tier  design;  standards  for  provider  admission  to participate in a network, including  reimbursement  rates;  methods  for determining usual, customary, and reasonable charges; fail-first or step therapy  protocols;  exclusions based on failure to complete a course of treatment; and restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or  duration of benefits for services provided under the contract.  (11)  A corporation shall provide coverage under this subsection, at a minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. § 1185a).  (ff)  (1)  No  managed  care  contract  issued  by  a  health  service corporation,  hospital  service corporation or medical expense indemnity corporation that provides coverage for  hospital,  medical  or  surgical care  shall  provide  that  services of a participating hospital will be covered as out-of-network services solely on the basis that  the  health care  provider  admitting  or rendering services to the insured is not a participating provider.  (2) No managed care contract issued by a health  service  corporation, hospital  service  corporation  or medical expense indemnity corporation  that provides coverage for hospital,  medical  or  surgical  care  shall provide  that  services  of a participating health care provider will be covered as out-of-network services solely on the basis that the services are rendered in a non-participating hospital.  (3)  For  purposes  of  this subsection, a "health care provider" is a health care professional licensed, registered or certified  pursuant  to title  eight  of  the  education  law  or  a  health  care  professional comparably licensed, registered or certified by another state.  (4) For purposes of this subsection, a "managed care  contract"  is  a contract   that  requires  that  services  be  provided  by  a  provider participating in the corporation's network in order for  the  subscriber to receive the maximum level of reimbursement under the contract.  (gg)  (1)  Every  contract  issued  by a hospital service corporation, health service corporation or medical expense indemnity corporation that includes coverage for dialysis treatment that requires such services  to be provided by an in-network provider and that does not provide coverage for  out-of-network  dialysis  treatment shall not deny coverage of such services  because  the  services  are  provided  by  an   out-of-network provider, provided that each of the following conditions are met:  (A)  The  out-of-network  provider  is  duly  licensed to practice and authorized to provide such treatment;  (B) The out-of-network provider is located outside the service area of the insurer;  (C) The in-network healthcare provider treating the covered person for the condition issues a written order for dialysis treatment stating that in his or her opinion such treatment is necessary;  (D) The covered person has notified, in writing,  the  corporation  at least  thirty  days  in  advance  of  the proposed date or dates of such out-of-network  dialysis  treatment.  The  notice  shall   include   the authorization  required  by  subparagraph  (C) of this paragraph. In the event the covered person must travel on sudden notice due to  family  or other  emergency,  shorter  notice  may  be permitted, provided that the corporation  has  reasonable  opportunity  to  review  the  travel   and treatment plans of the covered person;  (E)  The  corporation shall have the right to pre-approve the dialysis treatment and schedule; and  (F) Such coverage is limited to no  greater  than  ten  out-of-network treatments in a calendar year.  (2)  Where  coverage for out-of-network dialysis treatment is provided pursuant to paragraph one of this subsection, no  corporation  shall  be obligated  to reimburse the out-of-network provider at an amount greater than it would have  paid  for  the  same  treatment  within  a  network, including  all  drugs and ancillary services tied to dialysis treatment, and any amount charged by a provider in excess of the amount  reimbursed by  the  corporation  shall  be the responsibility of the covered person receiving the out-of-network services.  (3) Such coverage of  out-of-network  dialysis  services  required  by paragraph  one  of  this  subsection  shall  otherwise be subject to the limitations, exclusions and terms of  the  policy,  including,  but  not limited  to,  utilization  review,  annual  deductibles, copayments, and coinsurance, consistent with those required for other  similar  benefits under the policy.  (hh)  Notwithstanding  title  eleven  of  article  five  of the social services law or any other  law  to  the  contrary,  every  policy  which provides  coverage for prescription drugs shall, with regard to eye drop medication requiring a  prescription  that  has  been  approved  by  the insurer   for   coverage,   allow  for  the  limited  refilling  of  the prescription prior to the last day of the approved dosage period without  regard to  any  coverage  restrictions  on  early  refill  of  renewals. Provided,  however, that any refill dispensed prior to the expiration of the prescribed and approved coverage period pursuant to this subsection, shall,  to  the  extent practicable, be limited in quantity so as not to exceed the remaining dosage initially approved for  coverage.  Provided, further,  that  such  limited  refilling  shall  not  limit  or restrict coverage  with  regard  to  any  previously  or  subsequently   approved prescription  for  eye drop medication and shall be subject to the terms and conditions of the policy  otherwise  applicable  to  this  coverage. Provided,  further,  that  a  pharmacist  may  contact  the  prescribing physician or health care provider to verity the prescription.  (ii) Every contract issued by a corporation subject to the  provisions of  this  article  which  provides  medical,  major  medical  or similar comprehensive-type coverage that includes coverage  for  a  physical  or well  care  visit  once  in every three hundred sixty-five days shall be interpreted to mean that such physical or well care  visit  can  be  had once every calendar year, regardless of whether or not a period of three hundred  sixty-five  days has passed since the previous physical or well care visit.  (jj) No medical expense  indemnity  corporation,  a  hospital  service corporation  or a health service corporation which provides coverage for prescription  drugs  and  for   which   cost-sharing,   deductibles   or co-insurance  obligations  are  determined  by  category of prescription drugs shall impose cost-sharing, deductibles or co-insurance obligations for  any  prescription  drug  that  exceeds   the   dollar   amount   of cost-sharing,  deductibles or co-insurance obligations for non-preferred brand  drugs  or  its  equivalent  (or  brand  drugs  if  there  is   no non-preferred brand drug category).  (kk) Any contract issued by a medical expense indemnity corporation, a hospital  service  corporation  or  a  health  services corporation that provides coverage for  prescription  drugs  shall  permit  each  covered person  to  fill  any  covered  prescription  that  may be obtained at a network participating mail order or other non-retail  pharmacy,  at  the covered  person's  option,  at  a  network  participating non-mail order retail pharmacy provided that the network participating  non-mail  order retail  pharmacy  agrees  in  advance,  through  a  contractual  network agreement, to the  same  reimbursement  amount,  as  well  as  the  same applicable  terms  and  conditions, that the corporation has established for the network participating mail order or other  non-retail  pharmacy. In  such  a case, the contract shall not impose a copayment fee or other condition on any covered person who elects  to  purchase  drugs  from  a network  participating  non-mail order retail pharmacy which is not also imposed on covered persons electing to purchase  drugs  from  a  network participating   mail  order  or  other  non-retail  pharmacy;  provided, however, that the provisions of this section  shall  not  supersede  the terms  of  a collective bargaining agreement or apply to a contract that is the result of a collective bargaining agreement between  an  employer and a recognized or certified employee organization.  (ll)  Every  small group contract or association group contract issued by a corporation subject to the provisions of this article that provides coverage for hospital, medical or surgical expense insurance and is  not a  grandfathered  health  plan  shall provide coverage for the essential health benefits package. For purposes of this subsection:  (1) "essential health benefits package" shall  have  the  meaning  set forth  in  paragraph  three  of  subsection (e) of section four thousand three hundred six-h of this article;  (2)  "grandfathered  health  plan"  means  coverage  provided   by   a corporation  in  which an individual was enrolled on March twenty-third,  two thousand ten for as long as  the  coverage  maintains  grandfathered status in accordance with section 1251(e) of the affordable care act, 42 U.S.C. § 18011(e); and  (3)  "small  group" means a group of one hundred or fewer employees or members exclusive of spouses and dependents; and  (4) "association group" means a group defined  in  subparagraphs  (B), (D),  (H), (K), (L) or (M) of paragraph one of subsection (c) of section four thousand two hundred thirty-five of this chapter, provided that:  (A) the group includes one or more individual members; or  (B) the group includes one or more member employers  or  other  member groups that are small groups.  (mm)  A corporation shall not be required to offer the contract holder any benefits that must be made available pursuant  to  this  section  if such  benefits  must  be  covered  pursuant  to  subsection (kk) of this section. For any contract issued  within  the  health  benefit  exchange established  by this state, a corporation shall not be required to offer the contract holder any benefits that must be made available pursuant to this section.  (nn) A corporation subject to the provisions of  this  article  or  an insurance  producer subject to this chapter shall not permit the renewal of a small group policy which provides  hospital,  surgical  or  medical expense  coverage  that  renews  on or after January first, two thousand fourteen, but before July first, two thousand fourteen, so as  to  renew the  same  policy prior to the policy's annual renewal date for the sole purpose of evading the requirements  of  the  affordable  care  act  and regulations  promulgated  thereunder  with  respect  to  such policy. An isolated, inadvertent renewal date change which was  not  made  for  the sole  purpose  of  evading  the  requirements of the affordable care act shall not be deemed a violation of this subsection.  (oo) A medical  expense  indemnity  corporation,  a  hospital  service corporation  or  a health service corporation that provides coverage for hospital, surgical or medical care shall provide the following  coverage for pasteurized donor human milk (PDHM), which may include fortifiers as medically  indicated,  for  inpatient  use, for which a licensed medical practitioner has issued an order for  an  infant  who  is  medically  or physically  unable  to  receive  maternal  breast milk or participate in breast feeding or whose mother is  medically  or  physically  unable  to produce  maternal  breast  milk  at  all  or in sufficient quantities or participate in breast feeding despite optimal  lactation  support.  Such infant  shall:  (i)  have  a  documented  birth  weight of less than one thousand five hundred grams; or  (ii)  have  a  congenital  or  acquired condition  that  places  the  infant  at  a high risk for development of necrotizing enterocolitis.  (pp) No contract issued by a medical  expense  indemnity  corporation, hospital   service  corporation,  or  health  service  corporation  that provides  reimbursement  for  non-physician  surgical  first   assistant services  when  the  services  are  provided by a non-physician surgical first assistant shall exclude  such  coverage  on  the  basis  that  the non-physician  surgical  first  assistant  services  were performed by a registered nurse first assistant provided that: (1) the registered nurse first assistant is certified in operating room nursing; (2) the services are within the scope of  practice  of  a  non-physician  surgical  first assistant;  and  (3)  the terms and conditions of the contract otherwise provide for the coverage of the services.  Nothing  in  this  subsection shall  be  construed  to  prevent  the medical management or utilization review of the services or prevent a policy from requiring that  services are to be provided through a network of participating providers who meet  certain    requirements    for    participation,    including   provider credentialing.   * (qq)  Every  medical expense indemnity corporation, hospital service corporation or health service corporation  that  provides  coverage  for prescription drugs subject to a copayment shall charge a copayment for a limited  initial  prescription of an opioid drug, which is prescribed in accordance  with  paragraph  (b)  of   subdivision   five   of   section thirty-three  hundred  one  of the public health law, that is either (i) proportional between the copayment  for  a  thirty-day  supply  and  the amount  of  drugs  the patient was prescribed; or (ii) equivalent to the copayment for a full thirty-day supply of the opioid drug, provided that no additional copayments may be charged for any additional prescriptions for the remainder of the thirty-day supply.   * NB There are 2 sb§ (qq)'s   * (qq) Whenever in this section a corporation is required  to  provide benefits with no coinsurance or deductible, the requirement only applies with respect to participating providers in the corporation's network, or with respect to non-participating providers, if the corporation does not have  a participating provider in the in-network benefits portion of its network with  the  appropriate  training  and  experience  to  meet  the particular   health  care  needs  of  the  covered  person  pursuant  to subsection (d) of section four thousand  three  hundred  six-c  of  this article,  or as applicable, pursuant to paragraph (a) of subdivision six of section forty-four hundred three of the public health law.   * NB There are 2 sb§ (qq)'s  (rr) Health care forensic examinations performed pursuant  to  section twenty-eight  hundred  five-i of the public health law covered under the contract shall not be subject to annual deductibles or coinsurance.