NY Ins L § 3217-I (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3217-I - Essential Health Benefits Package and Limit on Cost-Sharing.

§ 3217-i. Essential health benefits package and limit on cost-sharing. (a)  (1) For purposes of this article, "essential health benefits" shall mean the following categories of benefits:  (A) ambulatory patient services;  (B) emergency services;  (C) hospitalization;  (D) maternity and newborn care;  (E) mental health  and  substance  use  disorder  services,  including behavioral health treatment;  (F) prescription drugs;  (G) rehabilitative and habilitative services and devices;  (H) laboratory services;  (I)  preventive  and wellness services and chronic disease management; and  (J) pediatric services, including oral and vision care.  (2) An insurer shall not be required to provide coverage for pediatric oral services as an essential health benefit if:  (A) for coverage offered through  the  exchange  established  by  this state,  the exchange has determined sufficient coverage of the pediatric oral benefit is available through stand-alone dental plans certified  by the exchange; or  (B)  for  coverage  offered  outside the exchange, the insurer obtains reasonable written assurance that the individual or group has obtained a stand-alone dental plan that has been approved by the superintendent  as meeting exchange certification standards.  (b) (1) Every individual and small group accident and health insurance policy that provides hospital, surgical, or medical expense coverage and is not a grandfathered health plan shall provide coverage that meets the actuarial requirements of one of the following levels of coverage:  (A)  Bronze Level. A plan in the bronze level shall provide a level of coverage that is designed  to  provide  benefits  that  are  actuarially equivalent  to sixty percent of the full actuarial value of the benefits provided under the plan;  (B) Silver Level. A plan in the silver level shall provide a level  of coverage  that  is  designed  to  provide  benefits that are actuarially equivalent to seventy  percent  of  the  full  actuarial  value  of  the benefits provided under the plan;  (C)  Gold  Level.  A  plan  in the gold level shall provide a level of coverage that is designed  to  provide  benefits  that  are  actuarially equivalent to eighty percent of the full actuarial value of the benefits provided under the plan; or  (D) Platinum Level. A plan in the platinum level shall provide a level of  coverage  that  is designed to provide benefits that are actuarially equivalent to ninety percent of the full actuarial value of the benefits provided under the plan.  (2) The superintendent may provide for a variation  in  the  actuarial values  used  in  determining the level of coverage of a plan to account for the differences in actuarial estimates.  (3) Every student accident and health insurance policy  shall  provide coverage  that  meets at least sixty percent of the full actuarial value of the benefits provided under the  policy.  The  policy's  schedule  of benefits  shall  include the level as described in paragraph one of this subsection nearest to, but below the actual actuarial value.  (c) Every individual or group accident  and  health  insurance  policy that provides hospital, surgical, or medical expense coverage and is not a  grandfathered  health  plan,  and  every  student accident and health insurance policy shall limit the insured's cost-sharing  for  in-network services  in  a  policy  year to not more than the maximum out-of-pocket  amount determined by the superintendent for all policies subject to this section. Such amount shall not exceed any annual out-of-pocket limit  on cost-sharing  set  by  the  United  States secretary of health and human services, if available.  (d)   The  superintendent  may  require  the  use  of  model  language describing  the  coverage  requirements  for  any  accident  and  health insurance  policy  form that is subject to the superintendent's approval pursuant to section three thousand two hundred one of this article.  (e) For purposes of this section:  (1) "actuarial value" means  the  percentage  of  the  total  expected payments  by the insurer for benefits provided to a standard population, without regard to the population to whom the insurer  actually  provides benefits;  (2)  "cost-sharing" means annual deductibles, coinsurance, copayments, or similar charges, for covered services;  (3) "essential health benefits package" means coverage that:  (A) provides for essential health benefits;  (B)  limits  cost-sharing  for  such  coverage  in   accordance   with subsection (c) of this section; and  (C) provides one of the levels of coverage described in subsection (b) of this section;  (4)  "grandfathered health plan" means coverage provided by an insurer in which an individual was enrolled on March twenty-third, two  thousand ten  for  as  long  as  the  coverage  maintains grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.  § 18011(e);  (5)  "small  group" means a group of one hundred or fewer employees or members exclusive of spouses and dependents; and  (6) "student accident and health insurance" shall have the meaning set forth in subsection (a) of section three thousand two hundred  forty  of this article.