NY Ins L § 3216 (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3216 - Individual Accident and Health Insurance Policy Provisions.

§  3216.  Individual  accident and health insurance policy provisions. (a) In this section the term:  (1) "Policy of accident and health insurance" includes any  individual policy  or contract covering the kind or kinds of insurance described in paragraph three of subsection (a) of section one  thousand  one  hundred thirteen of this chapter.  (2) "Indemnity" means benefits promised.  (3) "Family"  may  include  the  policyholder's  spouse,  or dependent children, or any other person dependent upon the policyholder.  (4) "Dependent children"  (A)  shall  include  any  children  under  a specified age which shall not exceed age nineteen except:  (i) Any unmarried dependent child, regardless of age, who is incapable of self-sustaining employment by reason of mental illness, developmental disability,  or mental retardation as defined in the mental hygiene law, or physical handicap and who became so incapable prior  to  the  age  at which dependent coverage would otherwise terminate, shall be included in coverage subject to any pre-existing conditions limitation applicable to other dependents; or  (ii)  Any  unmarried  student at an accredited institution of learning may be considered a dependent child until attaining age twenty-three for a policy other than hospital, medical, surgical,  or  prescription  drug expense insurance; or  (iii)  Any  married or unmarried child shall be considered a dependent child  until  attaining  age  twenty-six  without  regard  to  financial dependence,   residency   with  the  policyholder,  student  status,  or employment, for a policy of hospital, medical, surgical, or prescription drug expense insurance.  (B) may include, at the option of the  insurer,  any  unmarried  child until  attaining  age  twenty-five  for  a  policy  other than hospital, medical, surgical, or prescription drug expense insurance.  (C) In addition to the requirements of subparagraphs (A)  and  (B)  of this  paragraph, every insurer issuing a policy of hospital, medical, or surgical expense  insurance  pursuant  to  this  section  that  provides coverage for dependent children must make available and, if requested by the policyholder, extend coverage under the policy to an unmarried child through  age  twenty-nine, without regard to financial dependence who is not insured by or eligible for coverage under an employer health benefit plan as an employee or member, whether insured or self-insured, and  who lives,  works  or  resides  in New York state or the service area of the insurer. Such coverage shall be made available at the inception  of  all new  policies. Written notice of the availability of such coverage shall be delivered to the policyholder thirty days prior to the  inception  of such policy.  (b)   No   policy   of   accident   and  health  insurance,  including non-cancellable disability insurance, except as provided  in  subsection (h)  hereof,  shall  be  delivered  or issued for delivery in this state until the rate manual showing rates, rules and classifications of  risks for  use  in connection with such accident and health insurance policies or with  riders  or  endorsements  thereon,  has  been  filed  with  the superintendent.  (c)  No  policy of accident and health insurance shall be delivered or issued for delivery to any person in this state unless:  (1) The entire money and other considerations therefor  are  expressed therein.  (2)  The  time  at  which the insurance takes effect and terminates is expressed therein.  (3) It purports to insure only one person, except that  a  policy  may insure,  originally  or by subsequent amendment, members of a family, as  defined herein, upon the application of an adult member  of  the  family who shall be deemed the policyholder.  (4)  (A)  Coverage of an unmarried dependent child who is incapable of self-sustaining employment by reason of  mental  illness,  developmental disability, or mental retardation, as defined in the mental hygiene law, or  physical handicap and who became so incapable prior to attainment of the age at which dependent coverage would otherwise terminate and who is chiefly dependent upon such policyholder for  support  and  maintenance, shall  not terminate while the policy remains in force and the dependent remains in such condition, if the  policyholder  has  within  thirty-one days  of such dependent's attainment of the limiting age submitted proof of such dependent's incapacity as described herein.  (B) Coverage of a  dependent  spouse  or  named  insured  which  would terminate upon such spouse or named insured attaining the age prescribed in  subchapter  XVIII  of  the federal Social Security Act, 42 U.S.C. §§ 1395 et seq. ("medicare"), as the  age  of  first  eligibility  for  the benefits  provided by such law shall not so terminate, if such dependent spouse is not then eligible for all of such benefits, for as long as the policy remains in force and such dependent spouse remains ineligible  to receive  any  of  such  "medicare"  benefits,  provided  proof  of  such ineligibility is submitted to the insurer within thirty-one days of  the date  notice  of  termination of coverage be sent by first class mail by the insurer to the last known address of the policyholder.  (C) Any  family  coverage  shall  provide  that  coverage  of  newborn infants,  including  newly  born  infants  adopted  by  the  insured  or subscriber if such insured or subscriber takes physical custody  of  the infant upon such infant's release from the hospital and files a petition pursuant  to section one hundred fifteen-c of the domestic relations law within thirty days of birth; and provided  further  that  no  notice  of revocation  to  the  adoption  has  been  filed  pursuant to section one hundred fifteen-b of the domestic  relations  law  and  consent  to  the adoption  has  not  been  revoked, shall be effective from the moment of birth for injury or sickness including the necessary care and  treatment of  medically  diagnosed  congenital  defects  and  birth  abnormalities including premature birth, except that in cases of adoption, coverage of the initial hospital stay shall not be required where a birth parent has insurance coverage available for the  infant's  care.  In  the  case  of individual  coverage the insurer must also permit the person to whom the policy is issued to elect such coverage  of  newborn  infants  from  the moment of birth. If notification and/or payment of an additional premium or  contribution  is  required  to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of  birth  to  make  coverage effective  from the moment of birth. This election shall not be required in the case of student insurance.  (5) (A) Any family  policy  providing  hospital  or  surgical  expense insurance  (but  not  including such insurance against accidental injury only) shall provide that, in the event such  insurance  on  any  person, other  than  the  policyholder,  is  terminated because the person is no longer within the definition of the family as set forth  in  the  policy but  before  such  person  has  attained  the  limiting age, if any, for coverage of adults  specified  in  the  policy,  such  person  shall  be entitled  to have issued to that person by the insurer, without evidence of insurability, upon application therefor  and  payment  of  the  first premium,  within  sixty days after such insurance shall have terminated, an individual conversion  policy  that  contains  the  essential  health benefits  package  described  in  paragraph  three  of subsection (f) of section three thousand two hundred  seventeen-i  of  this  article.  The  insurer  shall  offer one policy at each level of coverage as defined in subsection (b) of section three thousand two hundred seventeen-i of this article. The individual may  choose  any  such  policy  offered  by  the insurer.  Provided,  however,  the  superintendent may, after giving due consideration to the public interest,  approve  a  request  made  by  an insurer for the insurer to satisfy the requirements of this subparagraph through  the  offering of policies that comply with this subparagraph by another insurer, corporation or health maintenance  organization  within the  insurer's  holding company system, as defined in article fifteen of this chapter.  The conversion privilege afforded herein  shall  also  be available  upon  the  divorce  or  annulment  of  the  marriage  of  the policyholder to the former spouse of such policyholder.  (B) Written notice of entitlement to  a  conversion  policy  shall  be given  by  the insurer to the policyholder at least fifteen and not more than sixty days prior to the termination of coverage due to the  initial limiting  age  of  the  covered  dependent. Such notice shall include an explanation of the rights of the dependent with respect to the dependent being  enrolled  in  an  accredited  institution  of  learning  or   his incapacity  for  self-sustaining employment by reason of mental illness, developmental disability or mental retardation as defined in the  mental hygiene law or physical handicap.  (C)  Such  individual  conversion  policy  shall  be  subject  to  the following terms and conditions:  (i) The premium shall be that applicable to the  form  and  amount  of insurance therefor.  (ii)  The  benefits  provided under such policy shall become effective upon the date that such person was no longer eligible under  the  family policy.  (iii)  No insurer shall be required to issue a conversion policy if it appears that the person applying for such policy shall have at that time in force another insurance policy or hospital service or medical expense indemnity contract providing similar benefits or is  covered  by  or  is eligible  for coverage by a group insurance policy or contract providing similar benefits or shall be covered by similar benefits required by any statute or provided by any welfare plan or program, which together  with the  conversion  policy would result in over insurance or duplication of benefits according to standards on file with the superintendent relating to individual policies.  (6) The style, arrangement and overall appearance of the  policy  give no undue prominence to any portion of the text, and unless every printed portion  of  the  text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than  ten-point  with  a lower-case   unspaced   alphabet   length  not  less  than  one  hundred twenty-point (the "text" shall include all  printed  matter  except  the name  and address of the insurer, name or title of the policy, the brief description, if any, and captions and subcaptions).  (7) The exceptions and reductions of indemnity are set  forth  in  the policy  and,  except those which are set forth in subsection (d) of this section, are printed, at the insurer's option, either included with  the benefit  provision  to which they apply, or under an appropriate caption such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided  that  if an  exception  or  reduction  specifically  applies only to a particular benefit of the policy, a statement of such exception or reduction  shall be included with the benefit provision to which it applies.  (8)  Each  such  form,  including  riders  and  endorsements, shall be identified by a form number in the lower left-hand corner of  the  first page thereof.  (9)  It  contains  no  provision purporting to make any portion of the charter, rules, constitution, or by-laws of the insurer a  part  of  the policy unless such portion is set forth in full in the policy, except in the  case of the incorporation of, or reference to, a statement of rates or   classification  of  risks,  or  short-rate  table  filed  with  the superintendent.  (10) There is prominently printed on the first page thereof  or  there is  attached  thereto  a  notice  to  the effect that during a specified period of time, which shall not be less than  ten  days  nor  more  than twenty  days  from the date the policy is delivered to the policyholder, it may be surrendered to the insurer together with a written request for cancellation of the policy and in such event the insurer will refund any premium paid therefor  including  any  policy  fees  or  other  charges, provided, however, that this paragraph shall not apply to single premium nonrenewable  policies  insuring  against  accidents  only or accidental bodily injuries only; provided, however, that a contract or  certificate sold  by  mail  order  and  a contract or certificate providing medicare supplemental insurance  or  long-term  care  insurance  must  contain  a provision  permitting  the  contract  or certificate holder a thirty day period for such surrender.  (11) The age limit or date or period, if any, after which the coverage provided by the policy will not be effective or the age limit,  date  or period  after which the policy may not be renewed is stated in a renewal provision set forth on the first page of the policy  or  as  a  separate provision bearing an appropriate caption on the first page of the policy or in a brief description in not less than fourteen-point bold face type set  forth  on  the  first  page of the policy. Nothing herein contained shall limit or restrict the right of the insurer to continue the  policy after the age or period so stated.  (12)  Any  policy,  other  than  one  issued  in  fulfillment  of  the continuing care responsibilities of an operator  of  a  continuing  care retirement  community in accordance with article forty-six of the public health  law,  made  available  because  of  residence  in  a  particular facility,  housing development, or community shall contain the following notice in twelve point type in bold face on the first page:   "NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF  A  CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."  (13)  Any  persons  covered  by  the  policy who are also members of a reserve component of the armed forces of the  United  States,  including the  National  Guard,  shall  be entitled, upon written request, to have their coverage suspended during a period of  active  duty  as  described herein.    The  policy  shall  provide  that the insurer will refund any unearned premiums for the period of such suspension. Persons covered  by the  policy  shall  be  entitled to resumption of coverage, upon written application and payment of the required premium within sixty days  after the  date  of  termination  of  the  period  of  active  duty,  with  no limitations or conditions imposed as a result of such period  of  active duty  except  as set forth in subparagraphs (A) and (B) herein. Coverage shall be retroactive to the date of termination of the period of  active duty.  Such right of resumption provided for herein shall be in addition to other existing rights granted pursuant to state and federal laws  and regulations  and  shall not be deemed to qualify or limit such rights in any way. No exclusion or waiting period may  be  imposed  in  connection with  coverage of a health or physical condition of a person entitled to such right of resumption, or a health or physical condition of any other person who is covered by the policy unless:  (A) the condition arose during the  period  of  active  duty  and  the condition has been determined by the secretary of veterans affairs to be a condition incurred in the line of duty; or  (B)  a  waiting period was imposed and had not been completed prior to the period of suspension; in no event, however, shall  the  sum  of  the waiting  periods  imposed  prior  to  and  subsequent  to  the period of suspension exceed the length of the waiting period originally imposed.  (14) To be entitled to the right defined in paragraph thirteen of this subsection a person must be a member of a component of the armed  forces of the United States, including the National Guard, who either:  (A)  voluntarily  or involuntarily enters upon active duty (other than for the purpose of determining his or her  physical  fitness  and  other than for training), or  (B)  has  his or her active duty voluntarily or involuntarily extended during a period when the president is authorized to order units  of  the ready reserve or members of a reserve component to active duty, provided that  such  additional  active  duty  is  at  the  request  and  for the convenience of the federal government, and  (C) serves no more than four years of active duty.  (d) Each policy of accident and health insurance delivered  or  issued for  delivery  to  any person in this state shall contain the provisions specified herein  in  the  words  in  which  the  same  appear  in  this subsection,  except  that the insurer may, at its option, substitute for one or more of such provisions  corresponding  provisions  of  different wording  approved  by the superintendent which are not less favorable in any respect to the insured or the beneficiary. Each provision  contained in  the policy shall be preceded by the applicable caption herein or, at the insurer's option, by such appropriate captions or subcaptions as the superintendent may approve.  (1) Each policy shall, except with respect to designation  by  numbers or letters as used below, contain the following provisions:  (A)  ENTIRE CONTRACT; CHANGES: This policy, including the endorsements and the attached papers, if any,  constitutes  the  entire  contract  of insurance.  No change in this policy shall be valid until approved by an executive officer of the insurer and unless such  approval  be  endorsed hereon  or  attached  hereto. No agent or broker has authority to change this policy or to waive any of its provisions.  (B) TIME LIMIT ON CERTAIN DEFENSES:  (i) After two  years  from  the  date  of  issue  of  this  policy  no misstatements, except fraudulent misstatements, made by the applicant in the  application  for such policy shall be used to void the policy or to deny a claim for loss incurred or disability (as defined in the  policy) commencing after the expiration of such two year period.The foregoing policy provision shall not be so construed as to affect any  legal  requirement  for  avoidance of a policy or denial of a claim during such initial two year period, nor to  limit  the  application  of subparagraphs (A) through (E), inclusive, of this paragraph in the event of misstatement with respect to age or occupation or other insurance.)A policy which the insured has the right to continue in force subject to  its  terms by the timely payment of premium until at least age fifty or, in the case of a policy issued after age forty-four,  for  at  least five  years from its date of issue, may contain in lieu of the foregoing the following provision (from which the clause  in  parentheses  may  be omitted at the insurer's option) under the caption "INCONTESTABLE":   After  this  policy has been in force for a period of two years during the lifetime of the insured  (excluding  any  period  during  which  the insured is disabled), it shall become incontestable as to the statements contained in the application.)  (ii)  No  claim  for  loss  incurred  or disability (as defined in the policy) commencing after two years from the date of issue of this policy shall be reduced or denied on the ground  that  a  disease  or  physical condition  not  excluded  from  coverage by name or specific description effective on the date of loss had existed prior to the effective date of coverage of this policy.  (C) GRACE PERIOD: A grace period of ........................ (insert a number  not  less than "7" for weekly premium policies, "10" for monthly premium policies and "31" for all other policies) days will  be  granted for  the  payment  of  each premium falling due after the first premium, during which grace period the policy shall continue in force.A policy in which the insurer reserves the right  to  refuse  renewal shall  have,  at  the  beginning  of  the above provision, the following clause:   "Unless not less than thirty  days  prior  to  the  renewal  date  the insurer  has delivered to the insured or has sent by first class mail to his last address as shown by the records of the insurer  written  notice of  its  intention  not to renew this policy beyond the period for which the premium has been accepted,"   Furthermore, such a policy, except an accident only policy, shall also provide in substance, in a  provision  thereof,  or  in  an  endorsement thereon  or  in  a  rider  attached thereto, that the insurer may refuse renewal of the policy only as of  the  renewal  date  occurring  on,  or nearest  its  first anniversary, or as of an anniversary of such renewal date, or at the option of the insurer as of the renewal  date  occurring on or nearest the anniversary of its date of last reinstatement.)  (D)  REINSTATEMENT: If any renewal premium be not paid within the time granted the insured for payment, a subsequent acceptance of the  premium by  the insurer or by any agent or broker duly authorized by the insurer to accept such premium, without requiring  in  connection  therewith  an application  for  reinstatement,  shall  reinstate the policy; provided, however, that if the  insurer  or  such  agent  or  broker  requires  an application  for  reinstatement and issues a conditional receipt for the premium tendered, the policy will be reinstated upon  approval  of  such application   by  the  insurer  or,  lacking  such  approval,  upon  the forty-fifth day following the date of such  conditional  receipt  unless the  insurer  has  previously  notified  the  insured  in writing of its disapproval of such application. The reinstated policy shall cover  only loss resulting from such accidental injury as may be sustained after the date  of  reinstatement  and loss due to such sickness as may begin more than ten days after such date. In all other  respects  the  insured  and insurer  shall  have  the  same  rights thereunder as they had under the policy immediately before the due date of the defaulted premium, subject to any provisions endorsed hereon or attached hereto in connection  with the   reinstatement.   Any   premium   accepted  in  connection  with  a reinstatement shall be applied to a period for  which  premium  has  not been  previously  paid, but not to any period more than sixty days prior to the date of reinstatement.The last sentence of the above provision  may  be  omitted  from  any policy  which  the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or, in the case of a policy issued after age forty-four, for at  least  five years from its date of issue.)  (E)  NOTICE  OF  CLAIM:  Written  notice of claim must be given to the insurer within twenty days after the occurrence or commencement  of  any loss  covered  by  the  policy,  or  as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or the beneficiary to the insurer at -------------- (insert the location of such office  as  the  insurer  may designate for the purpose), or to any authorized agent of the insurer or to any authorized broker, with information  sufficient to  identify  the  insured, shall be deemed notice to the insurer. (In a policy  providing  a  loss-of-time  benefit  which may be payable for at least two years, an insurer may  at  its  option  insert  the  following between  the  first and second sentences of the above provision: Subject to the qualifications set forth below, if the insured  suffers  loss  of time  on account of disability for which indemnity may be payable for at least two years, he shall, at least  once  in  every  six  months  after having  given notice of claim, give to the insurer notice of continuance of said disability, except in the event of legal incapacity. The  period of  six  months  following  any  filing  of  proof by the insured or any payment by the insurer on  account  of  such  claim  or  any  denial  of liability  in  whole  or  in  part  by  the insurer shall be excluded in applying this provision. Delay in the giving of such  notice  shall  not impair  the  insured's right to any indemnity which would otherwise have accrued during the period of six months preceding the date on which such notice is actually given.)  (F) CLAIM FORMS: The insurer, upon receipt of a notice of claim,  will furnish  to  the  claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not  furnished  within  fifteen days  after  the  giving  of such notice the claimant shall be deemed to have complied with the requirements of this policy as to proof  of  loss upon  submitting,  within the time fixed in the policy for filing proofs of loss, written proof covering the occurrence, the character and extent of the loss for which claim is made.  (G) PROOFS OF LOSS: Written proof of loss must  be  furnished  to  the insurer  at  its  said  office  in case of claim for loss for which this policy provides any periodic payment  contingent  upon  continuing  loss within  ninety  days  after  the termination of the period for which the insurer is liable and in case of claim for any  other  loss  within  one hundred twenty days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if  it  was  not  reasonably  possible  to  give proof within such time, provided such proof is furnished as soon as reasonably possible  and  in no  event,  except in the absence of legal capacity, later than one year from the time proof is otherwise required.  (H) TIME OF PAYMENT OF CLAIMS: Indemnities payable under  this  policy for any loss other than loss for which this policy provides any periodic payment  will  be  paid immediately upon receipt of due written proof of such loss. Subject to due written proof of loss, all accrued indemnities for loss for  which  this  policy  provides  periodic  payment  will  be paid ------------ (insert  period  for  payment  which  must not be less frequently than monthly) and  any  balance  remaining  unpaid  upon  the termination  of  liability  will be paid immediately upon receipt of due written proof.  (I) PAYMENT OF CLAIMS: Any indemnity for loss of life will be  payable in  accordance  with  the  beneficiary  designation  and  the provisions respecting such payment which may be prescribed herein and effective  at the  time  of  payment.  If  no  such  designation  or provision is then effective, such indemnity shall be payable to the estate of the insured. Any other accrued indemnities unpaid at the insured's death may, at  the option  of  the  insurer,  be paid either to such beneficiary or to such estate. All other indemnities will be payable  to  the  insured.The following  provisions,  or  either  of  them,  may  be included with the foregoing provision at the option of the insurer: If  any  indemnity  of this  policy  shall  be  payable  to the estate of the insured, or to an insured or beneficiary who is a minor or otherwise not competent to give  a valid release, the insurer may pay such indemnity, up to an amount not exceeding $-------------- (insert an amount which shall not  exceed  one thousand dollars), to any relative by blood or connection by marriage of the  insured or beneficiary who is deemed by the insurer to be equitably entitled thereto. Any payment made by the insurer in good faith pursuant to this provision shall fully discharge the insurer  to  the  extent  of such payment.   Subject  to any written direction of the insured in the application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical, or surgical services may, at  the insurer's  option  and  unless the insured requests otherwise in writing not later than the time of filing proofs of such loss, be paid  directly to  the  hospital  or  person  rendering  such  services;  but it is not required that the service  be  rendered  by  a  particular  hospital  or person.)  (J)  PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense shall have the right and  opportunity  to  examine  the  person  of  the insured  when  and  as  often  as  it  may reasonably require during the pendency of a claim hereunder and to make an autopsy in  case  of  death where it is not forbidden by law.  (K)  LEGAL  ACTIONS: No action at law or in equity shall be brought to recover on this policy prior to  the  expiration  of  sixty  days  after written  proof  of  loss  has  been  furnished  in  accordance  with the requirements of this policy. No such action shall be brought  after  the expiration  of  three  years  after  the  time  written proof of loss is required to be furnished.  (L) CHANGE OF BENEFICIARY: Unless the  insured  makes  an  irrevocable designation  of  beneficiary,  the  right  to  change  of beneficiary is reserved  to  the  insured  and  the  consent  of  the  beneficiary   or beneficiaries  shall not be requisite to surrender or assignment of this policy or to any change of beneficiary or beneficiaries, or to any other changes in this policy. (The first  clause  of  this  provision,  relating  to  the  irrevocable designation of beneficiary, may be omitted at the insurer's option.)  (M)  "CONVERSION  PRIVILEGE"  (under  this  caption) a provision which shall set forth in  substance  the  conversion  privileges  and  related provisions  required of certain policies by paragraph five of subsection (c) of this section.  (2) Other provisions. No such policy delivered or issued for  delivery to  any  person  in  this  state shall contain provisions respecting the matters set forth below unless such provisions are  in  the  words  (not including  the designation by number or letter) in which the same appear in this paragraph except that the insurer may, at  its  option,  use  in lieu  of  any  such  provision  a  corresponding  provision of different wording approved by the superintendent which is not  less  favorable  in any  respect  to  the  insured  or  the  beneficiary. Any such provision contained  in  the  policy  shall  be  preceded  individually   by   the appropriate  caption  appearing herein or, at the option of the insurer, by such appropriate individual or group captions or subcaptions  as  the superintendent may approve.  (A)  CHANGE  OF  OCCUPATION:  If  the  insured  be injured or contract sickness after having changed his occupation to one  classified  by  the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer  will  pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and  within the  limits  fixed by the insurer for such more hazardous occupation. If the insured changes his occupation to one classified by the  insurer  as  less  hazardous  than  that  stated  in  this  policy, the insurer, upon receipt of proof of such change of occupation, will reduce  the  premium rate  accordingly,  and will return the excess pro-rata unearned premium from  the  date  of  change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the  more recent.  In  applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by  the insurer  prior  to  the  occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the  state official  having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing  was  not required,  then  the classification of occupational risk and the premium rates shall be those last made effective by the insurer  in  such  state prior  to  the  occurrence  of the loss or prior to the date of proof of change in occupation.  (B) MISSTATEMENT OF AGE: If the insured's age has been misstated,  all amounts  payable  under  this  policy  shall be such as the premium paid would have purchased at the correct age.  (C) OTHER INSURANCE IN THIS INSURER: If an  accident  or  sickness  or accident  and health policy or policies previously issued by the insurer to the insured be in force concurrently herewith,   making  the  aggregate  indemnity  for  ------------(insert  type   of coverage  or coverages) in excess of $-------------(insert maximum limit of indemnity or indemnities) the excess insurance shall be void and  all premiums paid for such excess shall be returned to the insured or to his estate, or, in lieu thereof:   Insurance effective at any one time on the insured under a like policy or policies in this insurer is limited to the one such policy elected by the  insured, his beneficiary or his estate, as the case may be, and the insurer will return all premiums paid for all other such policies.  (D) INSURANCE WITH OTHER INSURERS: If there be other  valid  coverage, not  with  this  insurer,  providing  benefits  for  the  same loss on a provision of service basis or on an expense incurred basis and of  which this  insurer  has not been given written notice prior to the occurrence or commencement of loss, the only liability under any  expense  incurred coverage  of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable hereunder plus the  total of  the  like  amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the  total  like  amounts under  all  valid  coverages  for  such loss, and for the return of such portion of the premiums paid as shall exceed the  pro-rata  portion  for the  amount  so  determined.  For the purpose of applying this provision when other coverage is on  a  provision  of  service  basis,  the  "like amount"  of  such  other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage.If the foregoing policy provision is included in a policy which  also contains the next following policy provision there shall be added to the caption  of  the  foregoing  provision  the phrase "--- EXPENSE INCURRED BENEFITS". The insurer may, at its option, include in this  provision  a definition  of  "other  valid  coverage",  approved  as  to  form by the superintendent, which definition shall be limited in subject  matter  to coverage  provided  by  organizations subject to regulation by insurance law or by insurance authorities of this or any other state of the United States or any province of Canada, and by  hospital  or  medical  service organizations,  and  to any other coverage the inclusion of which may be approved by the superintendent. In the absence of such  definition  such term  shall  not  include  group  insurance, automobile medical payments  insurance,  or  coverage  provided  by  hospital  or   medical   service organizations  or by union welfare plans or employer or employee benefit organizations. For the purpose of applying the foregoing provision  with respect  to any insured, any amount of benefit provided for such insured pursuant to any  compulsory  benefit  statute  (including  any  workers' compensation  or  employer's  liability  statute)  whether provided by a governmental agency or otherwise shall in all  cases  be  deemed  to  be "other  valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability  coverage  shall be included as "other valid coverage".)  (E)  INSURANCE  WITH OTHER INSURERS: If there be other valid coverage, not with this insurer, providing benefits for the  same  loss  on  other than  an  expense  incurred basis and of which this insurer has not been given written notice prior to the occurrence or  commencement  of  loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as  the  like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the  total  amount  of  all  like indemnities  for  such  loss,  and for the return of such portion of the premium paid as shall exceed the pro-rata portion  for  the  indemnities thus determined.If  the foregoing policy provision is included in a policy which also contains the next preceding policy provision there shall be added to the caption of the foregoing provision the phrase "--- OTHER BENEFITS".  The insurer  may,  at  its option, include in this provision a definition of "other valid coverage", approved as to form by the superintendent, which definition shall be limited in subject matter to  coverage  provided  by organizations  subject  to  regulation  by insurance law or by insurance authorities of this or any other state  of  the  United  States  or  any province of Canada, and to any other coverage the inclusion of which may be  approved  by  the  superintendent. In the absence of such definition such term shall not include group insurance,  or  benefits  provided  by union  welfare  plans  or by employer or employee benefit organizations. For the purpose of applying the foregoing policy provision with  respect to any insured, any amount of benefit provided for such insured pursuant to  any  compulsory benefit statute (including any workers' compensation or employer's liability statute)  whether  provided  by  a  governmental agency  or  otherwise  shall  in  all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision no third party liability coverage shall be included  as "other valid coverage".)  (F)  RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of loss of time benefits promised for the same loss under all valid loss of time coverage upon the insured, whether payable on a weekly  or  monthly basis,  shall  exceed  the  monthly  earnings of the insured at the time disability commenced or his average monthly earnings for the  period  of two  years  immediately  preceding a disability for which claim is made, whichever is the greater, the insurer  will  be  liable  for  only  such proportionate amount of such benefits under this policy as the amount of such  monthly  earnings  or such average monthly earnings of the insured bears to the total amount of monthly benefits for the  same  loss  under all such coverage upon the insured at the time such disability commences and  for  the  return  of such part of the premiums paid during such two years as shall exceed the  pro-rata  amount  of  the  premiums  for  the benefits  actually  paid hereunder; but this shall not operate to reduce the total monthly amount of benefits payable  under  all  such  coverage upon  the insured below the sum of two hundred dollars or the sum of the monthly benefits specified in such coverages, whichever is  the  lesser,  nor  shall  it  operate  to reduce benefits other than those payable for loss of time.The foregoing policy provision may be inserted only in a policy which the  insured  has the right to continue in force subject to its terms by the timely payment of premiums until at least age fifty or, in the  case of  a  policy  issued after age forty-four, for at least five years from its date of issue. The insurer may,  at  its  option,  include  in  this provision  a definition of "valid loss of time coverage", approved as to form by the superintendent, which definition shall be limited in subject matter to coverage provided by governmental agencies or by organizations subject to regulation by the insurance law or by  insurance  authorities of  this  or  any  other  state  of the United States or any province of Canada, or to any other coverage the inclusion of which may be  approved by  the  superintendent  or  any  combination  of such coverages. In the absence of such definition such term  shall  not  include  any  coverage provided  for  such  insured  pursuant to any compulsory benefit statute (including any workers' compensation or employer's  liability  statute), or  benefits  provided by union welfare plans or by employer or employee benefit organizations.)  (G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order  may be deducted therefrom.  (H)  CANCELLATION:  Within  the  first  ninety  days after the date of issue, the insurer may cancel this policy by written notice delivered to the insured, or sent by first class mail to his last address as shown by the records of the  insurer,  stating  when,  not  less  than  ten  days thereafter,  such  cancellation  shall  be  effective.  In  the event of cancellation, the insurer will return  promptly  the  pro-rata  unearned portion  of any premium paid. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.Nothing in this subsection shall be construed to prohibit an  insurer from  granting  to  the insured the right to cancel a policy at any time and to receive in such event a refund of the  unearned  portion  of  any premium  paid,  computed  by  the use of the short-rate table last filed with the state official having supervision of  insurance  in  the  state where the insured resided when the policy was issued).  (I)  CONFORMITY  WITH  STATE  STATUTES:  Any  provision of this policy which, on its effective date, is in conflict with the  statutes  of  the state  in  which  the  insured resides on such date is hereby amended to conform to the minimum requirements of such statutes.  (J) ILLEGAL OCCUPATION: The insurer shall not be liable for  any  loss to which a contributing cause was the insured's commission of or attempt to  commit  a  felony or to which a contributing cause was the insured's being engaged in an illegal occupation.  (K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any loss sustained or contracted  in  consequence  of  the  insured's  being intoxicated  or  under the influence of any narcotic unless administered on the advice of a physician.  (3) If any provision of  this  subsection  is  in  whole  or  in  part inapplicable  to  or  inconsistent  with  the  coverage  provided  by  a particular form  of  policy  the  insurer,  with  the  approval  of  the superintendent,  shall  omit from such policy any inapplicable provision or part of a provision, and shall modify any inconsistent  provision  or part  of  the  provision  in  such  manner  as  to make the provision as contained in the policy consistent with the  coverage  provided  by  the policy.  (4)  The provisions which are the subject of paragraphs one and two of this subsection, or any corresponding provisions which are used in  lieu  thereof  in  accordance  with  such  paragraphs, shall be printed in the consecutive order of the provisions in such paragraphs or, at the option of the insurer, any such provision may appear as a unit in any  part  of the  policy, with other provisions to which it may be logically related, provided the  resulting  policy  shall  not  be  in  whole  or  in  part unintelligible,  uncertain,  ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.  (5) The word  "insured",  as  used  in  this  section,  shall  not  be construed  as  preventing  a person other than the insured with a proper insurable interest from making  application  for  and  owning  a  policy covering  the  insured or from being entitled under such a policy to any indemnities, benefits and rights provided therein.  (6) The superintendent may make such reasonable rules and  regulations concerning  the  procedure  for  the  filing  or  submission of policies subject to this section as are necessary, proper  or  advisable  to  the administration  of  this  section.  This provision shall not abridge any other authority granted the superintendent by law.  (e) The acknowledgment by any insurer of the receipt of  notice  given under any policy covered by this section, or the furnishing of forms for filing  proofs  of  loss,  or  the  acceptance  of  such  proofs, or the investigation of any claim thereunder, shall not operate as a waiver  of any  of  the rights of the insurer in defense of any claim arising under such policy.  (f) If any such policy contains a provision establishing,  as  an  age limit  or  otherwise,  a  date  after which the coverage provided by the policy will not be effective, and if such date falls within a period for which premium is accepted by the insurer or if  the  insurer  accepts  a premium  after  such  date,  the  coverage  provided  by the policy will continue in force subject to any right of cancellation until the end  of the  period for which premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct  age  of the  insured,  the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such  premium or  premiums,  then the liability of the insurer shall be limited to the refund, upon request, of all premiums paid for the period not covered by the policy.  (g)(1) No insurer shall refuse to renew a policy of hospital, surgical or medical expense insurance, an individual  converted  policy,  or  any other  policy  in  which  one-third  or  more  of  the  total premium is allocable to hospital, surgical or  medical  expense  benefits,  or  any combination  thereof  (but  not  including  insurance against accidental injury only), except for one or more of the following reasons:  (A) nonpayment of premiums,  (B) fraud in applying for the policy or in applying for  any  benefits under the policy or intentional misrepresentation of material fact under the terms of the coverage,  (C) discontinuance of a class of policies in accordance with paragraph two of this subsection, except that no insurer or organization certified pursuant  to article forty-four of the public health law shall refuse to renew the policies of insureds holding  contracts  which  provide  major medical  or  similar comprehensive type coverage in effect prior to June first, two thousand one who are ineligible to purchase policies  offered pursuant  to  section  four  thousand  three  hundred twenty-one or four thousand three hundred twenty-two of this chapter due to the  provisions of  section  42 USC 1395ss in effect on January first, two thousand one, and who are eligible for Medicare benefits by reason of disability.  (i) Coverage shall be reinstated only for such insureds terminated  on or  after  January  first,  two  thousand one and such coverage shall be  reinstated on a prospective basis only, irrespective of any pre-existing conditions.  (ii)  In  the  event  any  such  insured  becomes eligible to purchase policies  offered  pursuant  to  section  four  thousand  three  hundred twenty-one  or  four  thousand three hundred twenty-two of this chapter, then such insured may be discontinued upon not  less  than  five  months prior written notice. In the event any such insured becomes eligible for Medicare  by  reason  of age, then such insured may be terminated by not less than thirty days notice with prior written notice.  (iii) Within sixty days of this item taking  effect,  the  insurer  or organization  shall  notify the insured of the prospective reinstatement of coverage under this section. Within thirty days of  receipt  of  such notice,  an  insured  shall notify the insurer or organization of his or her election for prospective coverage,  (D) discontinuance of  all  hospital,  surgical  and  medical  expense coverage  in  the  individual  market  in  this state in accordance with paragraph three of this subsection,  (E) in the case of an insurer that offers coverage in  the  individual market  through  a  network  plan,  termination  of an individual who no longer resides, lives or works in the service area (or in  an  area  for which  the  insurer  is  authorized  to  do  business)  but only if such coverage is terminated under this subparagraph uniformly without  regard to any health status-related factor of covered individuals, and  (F) for such other reasons as are acceptable to the superintendent and authorized by the Health Insurance Portability and Accountability Act of 1996,  Public  Law  104-191,  and  any  later  amendments  or  successor provisions, or by any federal regulations or rules  that  implement  the provisions of the Act.   In  no event shall any insurer refuse to renew any such policy because of the physical or mental condition or the health of any person  covered thereunder. Furthermore, no insurer shall require as a condition for the renewal  of  any  such policy any rider, endorsement or other attachment which shall  limit  the  nature  or  extent  of  the  benefits  provided thereunder.  The  superintendent  may require every insurer to file with him such  documents,  statistics  or  other  information  regarding  the refusal  to  renew permitted by this subsection as he may deem necessary for the proper administration of this subsection.  (2) In any case in which an insurer decides to discontinue offering  a class   of  hospital,  surgical  or  medical  expense  policies  in  the individual health insurance market, coverage of the  class  of  policies may be discontinued by the insurer only if:  (A)  the  insurer  gives  at least ninety days prior written notice of such discontinuance to the superintendent;  (B) the insurer provides written notice of such discontinuance to each covered  individual  at  least  ninety  days  prior  to  the   date   of discontinuance of such coverage;  (C)  the  insurer  offers  to  each  covered  individual the option to purchase all other individual hospital,  surgical  and  medical  expense coverage currently being offered by the insurer in the individual health insurance market; and  (D)  in  exercising  the  option to discontinue coverage of a class of policies and in offering the option of coverage under  subparagraph  (C) of  this  paragraph, the insurer acts uniformly without regard to claims experience or to any health status-related factor of insured individuals or individuals who may become eligible for such coverage.  (E) The superintendent may, after  giving  due  consideration  to  the public interest, approve a request made by an insurer for the insurer to satisfy  the  requirements of subparagraph (C) of this paragraph through  the offering of policies  at  each  level  of  coverage  as  defined  in subsection (b) of section three thousand two hundred seventeen-i of this article that contains the essential health benefits package described in paragraph  three of subsection (e) of section three thousand two hundred seventeen-i of this article by another insurer,  corporation  or  health maintenance  organization  within  the  insurer's  same  holding company system, as defined in article fifteen of this chapter.  (3) In any case in which an insurer elects to discontinue offering all hospital, surgical and medical expense coverage in the individual market in this state, health insurance coverage  may  be  discontinued  by  the insurer only if:  (A)  the  insurer gives at least one hundred eighty days prior written notice of such discontinuance to the superintendent;  (B) the insurer provides written notice of such discontinuance to each covered individual at least one hundred eighty days prior to the date of termination of such coverage;  (C) all hospital, surgical and  medical  expense  coverage  issued  or delivered  for  issuance  in  this  state  in  the  individual market is discontinued and coverage under such health insurance coverage  in  such market is not renewed; and  (D)  in addition to the notice referred to in subparagraph (A) of this paragraph, the insurer must provide the superintendent  with  a  written plan  to  minimize potential disruption in the marketplace occasioned by its withdrawal from the individual market.  (4) In the case of a discontinuance  under  paragraph  three  of  this subsection,  the  insurer may not provide for the issuance of any policy of hospital, surgical or medical expense  insurance  in  the  individual market  in  this state during the five year period beginning on the date of the discontinuance of the  last  health  insurance  coverage  not  so renewed.  (5)  At the time of coverage renewal, an insurer may modify the health insurance coverage for a policy  form  offered  to  individuals  in  the individual  market  so long as such modification is consistent with this chapter and effective on a uniform basis among all individuals with that policy form.  (6) For purposes of this subsection the term "network plan" shall mean a health insurance policy under which  the  financing  and  delivery  of health  care  (including  items  and services paid for as such care) are provided, in whole or in part, through a defined set of providers  under contract  with  the  insurer or another entity which has contracted with the insurer.  (h) This section shall not apply to or affect:  (1) Any contract of  non-cancellable  disability  insurance  which  is governed  by or excepted from section three thousand two hundred fifteen of this article.  (2) Any policy or contract of reinsurance.  (3) Any policy of group or blanket  insurance  which  is  governed  by section  three  thousand  two  hundred twenty-one of this article except that the provisions of subsection (b) hereof and paragraphs one  through ten of subsection (i) hereof and the provisions of subsection (j) hereof shall  be  applicable  to  a  policy of group insurance authorized under subparagraph (J) of paragraph one of  subsection  (c)  of  section  four thousand two hundred thirty-five of this chapter.  (4)  Any policy providing disability benefits pursuant to article nine of the workers' compensation law.  (5) Any policy of a co-operative life and accident  insurance  company except as was provided in section two hundred thirty-seven of the former insurance law.  (6)  Life  insurance,  endowment  or  annuity  contracts, or contracts supplemental thereto which contain  only  such  provisions  relating  to accident  and health insurance as provide additional benefits in case of death or dismemberment or loss of sight by accident, or  as  operate  to safeguard  such  contracts against lapse, or to give a special surrender value or special benefit or an annuity in the event that the insured  or annuitant  shall  become totally and permanently disabled, as defined by the contract or supplemental contract.  (i) Every person  insured  under  a  policy  of  accident  and  health insurance  delivered  or  issued  for  delivery  in  this state shall be entitled to the reimbursements and coverages specified below.  (1) If a policy provides for reimbursement for any optometric  service which  is within the lawful scope of practice of a licensed optometrist, the insured shall be entitled to reimbursement for such service  whether it  is  performed  by  a  physician or licensed optometrist. Unless such policy shall otherwise provide  there  shall  be  no  reimbursement  for ophthalmic  materials,  lenses, spectacles, eyeglasses, or appurtenances thereto.  (2) If a policy provides for reimbursement for any podiatrical service within the lawful scope  of  practice  of  a  licensed  podiatrist,  the insured  shall  be entitled to reimbursement for such service whether it is performed by a physician or licensed podiatrist.  (3) If a policy provides for  reimbursement  for  any  dental  service within  the  lawful scope of practice of a licensed dentist, the insured shall be entitled to  reimbursement  for  such  service  whether  it  is performed by a physician or a licensed dentist.  (4)  If  a  policy  provides  for  reimbursement  for  psychiatric  or psychological services or for diagnosis and treatment of  mental  health conditions  however defined in the policy, the insured shall be entitled to reimbursement for  such  services,  diagnosis  or  treatment  whether performed  by  a  physician,  psychiatrist,  a  certified and registered psychologist, or a nurse practitioner when  the  services  rendered  are within the lawful scope of their practice.  (5)  Every  policy providing for reimbursement for laboratory tests or reimbursement  for  diagnostic  X-ray   services   shall   provide   for reimbursement at the same percentage of reimbursement whether such tests or  services  are  provided  to  the insured as an admitted patient in a health care facility or as an out-patient.  (6) Every policy which provides coverage for in-patient hospital  care shall  provide  coverage  for home care to residents in this state. Such home care coverage shall  be  included  at  the  inception  of  all  new policies  and,  with  respect  to all other policies, at any anniversary date of the policy subject to evidence of insurability.  (A) Home care means the care and treatment of a covered person who  is under the care of a physician but only if hospitalization or confinement in  a  nursing  facility  as  defined in subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been required if home care was not provided, and the plan covering  the  home health service is established and approved in writing by such physician. 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 and 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.  (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 under the contract if the covered person had  been  hospitalized  or  confined  in  a skilled nursing facility as defined in title subchapter XVIII of the federal Social Security Act, 42 U.S.C.  §§ 1395 et seq.  (B) Coverage may be subject to an annual deductible of not  more  than fifty  dollars  for  each  person  covered  under  the policy and may be subject to a coinsurance provision which provides for  coverage  of  not less  than  seventy-five  percent  of  the  reasonable  charges for such services. 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 person covered under the contract; four hours of home health aide service shall be considered as one home care visit.  (7) Every policy which provides coverage for in-patient hospital  care shall  also  provide  coverage  for  pre-admission  tests  performed  in hospital out-patient facilities prior to scheduled surgery provided:  (A) the tests are ordered by a physician as a planned  preliminary  to admission  of  the  patient  as  an  in-patient  for surgery in the same hospital;  (B) tests are necessary for and  consistent  with  the  diagnosis  and treatment of the condition for which surgery is to be performed;  (C)  reservations  for  a hospital bed and for an operating room shall have been made prior to the performance of the tests;  (D) the surgery  actually  takes  place  within  seven  days  of  such presurgical tests; and  (E) the patient is physically present at the hospital for the tests.  (8)  Every policy 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.  (9)(A) Every policy that provides coverage for inpatient hospital care shall also include coverage 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 policy subject to this paragraph.  (C)  For  purposes of this paragraph, an "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 purposes of this paragraph, "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 purposes of this paragraph, "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  insured  from  a facility or to deliver a newborn child (including the placenta).  (10) (A) (i) Every policy which provides hospital, surgical or medical coverage  shall provide coverage for maternity care, including hospital, surgical or medical care to the same extent that hospital,  surgical  or medical  coverage  is  provided for illness or disease under the policy. 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 after 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.  (ii)  Maternity  care  coverage shall also include, at minimum, parent education, assistance and training in breast or bottle feeding, and  the performance of any necessary maternal and newborn clinical assessments.  (iii)  The  mother shall have the option to be discharged earlier than the time periods established in item (i) of this subparagraph.  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 policy. The policy 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 policy  and  subject  to  the  provisions  of this subparagraph, and not subject to deductibles, coinsurance or copayments.  (B) Coverage provided under this  paragraph  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.  (11) (A) Every policy that provides coverage for hospital, surgical or medical  care  shall  provide  the  following  coverage  for mammography screening for occult breast cancer:  (i)  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;  (ii) a single baseline mammogram, which  may  be  provided  by  breast tomosynthesis, for covered persons aged thirty-five through thirty-nine, inclusive; and  (iii)   an   annual   mammogram,  which  may  be  provided  by  breast tomosynthesis, for covered persons aged forty and older.  (B) Such coverage required pursuant to subparagraph (A) or (C) of this paragraph shall not be subject to annual deductibles or coinsurance.  (C) For purposes of subparagraphs  (A)  and  (B)  of  this  paragraph, 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 tomosynthesis.  (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph, every policy that provides coverage for hospital,  surgical  or  medical care,  except  for a grandfathered health plan under subparagraph (E) of this paragraph, shall provide coverage  for  the  following  mammography screening  services,  and  such  coverage shall not be subject to annual deductibles or coinsurance:  (i) 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  (ii) with respect  to  women,  such  additional  preventive  care  and screenings   for   mammography   not  described  in  item  (i)  of  this subparagraph and as provided for in comprehensive  guidelines  supported by the health resources and services administration.  (E)  For purposes of this paragraph, "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).  (F) Screening and diagnostic  imaging  for  the  detection  of  breast cancer, including diagnostic mammograms, breast ultrasounds, or magnetic resonance  imaging,  covered  under  the  policy shall not be subject to annual deductibles or coinsurance.  (11-a) (A) 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:  (i)  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  (ii)  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.  (B) Such coverage shall  not  be  subject  to  annual  deductibles  or coinsurance.  (12)  (A)  Every  policy  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.  (B)  Notwithstanding  the provisions of this paragraph, 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 paragraph 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.  (12-a) (A) Every policy delivered or issued for delivery in this state that  provides  medical,  major  medical,  or similar comprehensive-type coverage and provides coverage for prescription drugs and also  provides coverage  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.  (B)  An  insurer  providing  coverage  under  this  paragraph  and any participating entity through which the insurer  offers  health  services shall not:  (i) vary the terms of the policy for the purpose or with the effect of avoiding compliance with this paragraph;  (ii) provide incentives (monetary or otherwise) to encourage a covered person  to accept less than the minimum protections available under this paragraph;  (iii) 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;  (iv)  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  (v)  achieve compliance with this paragraph by imposing an increase in cost sharing for an intravenous or injected anticancer medication.  (13) (A) Every policy 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.  (B) Every policy 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.  (C) Every policy that  provides  medical,  major  medical  or  similar comprehensive-type   coverage   shall   provide  coverage  for  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 policy.  (i)  For purposes of this subparagraph, "iatrogenic infertility" means an impairment of fertility by surgery, radiation, chemotherapy or  other medical treatment affecting reproductive organs or processes.  (ii)   No  insurer  providing  coverage  under  this  paragraph  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.  (13-a) Every policy 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 insurer has established for a network participating mail  order or other non-retail pharmacy. In such case, the policy shall not impose  any  fee,  co-payment,  co-insurance,  deductible  or  other condition  on  any insured who elects to purchase prescription fertility drugs through a network participating  non-mail  order  retail  pharmacy that  it  does  not  impose  on  any  insured who purchases prescription fertility drugs through a network  participating  mail  order  or  other non-retail pharmacy.  (14)  If  a  policy  provides  for  reimbursement  for the services of licensed health professionals who can bill  for  services,  the  insured shall be entitled to 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.  (15) (A) Every policy that provides hospital, surgical or medical care coverage or provides reimbursement for laboratory tests or reimbursement for  diagnostic  X-ray  services  shall  provide  coverage for an annual cervical cytology screening for cervical cancer and its precursor states for women aged eighteen and older.  (B) For purposes of subparagraphs  (A)  and  (C)  of  this  paragraph, 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.  (C) Such coverage required pursuant to subparagraph (A) or (B) of 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 policy.  (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph, every policy that provides hospital, surgical or medical care  coverage, except  for  a  grandfathered health plan under subparagraph (E) of this paragraph, shall provide coverage for the  following  cervical  cytology screening  services,  and  such  coverage shall not be subject to annual deductibles or coinsurance:  (i) 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  (ii) with respect  to  women,  such  additional  preventive  care  and screenings  for  cervical  cytology  not  described  in item (i) of this subparagraph and as provided for in comprehensive  guidelines  supported by the health resources and services administration.  (E)  For purposes of this paragraph, "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).  (15-a) (A) Every policy 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.  (B) 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.  (16) If  a  policy  provides  for  reimbursement  for  speech-language pathology  or  audiology  service  which  is  within the lawful scope of practice of a duly licensed speech-language pathologist or  audiologist, an  insured  shall be entitled to reimbursement for such service whether the  said  service  is  performed  by  a  physician  or  duly   licensed speech-language  pathologist  or  audiologist,  provided  however,  that nothing contained herein shall be construed to impair any terms of  such policy  which  may  require  said  service to be performed pursuant to a medical order, or a similar or related service of a physician, in  which case  coverage  need  not  be  provided  for  any  tests, evaluations or diagnoses if such tests, evaluations  or  diagnoses  have  already  been provided  by or through a physician within twelve months of the referral or order from the physician. However, nothing herein shall be  construed as  preventing an insurer from covering more than one test or evaluation provided by  a  speech-language  pathologist  or  audiologist  within  a twelve-month  period  where  such  test  or  evaluation  is ordered by a physician as medically necessary. Nor shall anything herein be construed as prohibiting the  limitation  of  such  services,  where  covered,  to specified  settings other than offices, such as hospitals or to services provided by such professionals as part of a home care agency's services.  (17) (A) Every policy that provides medical, major-medical or  similar comprehensive-type  coverage shall provide coverage for the provision of preventive and primary care services.  (B) For the purposes  of  subparagraphs  (A),  (C)  and  (D)  of  this paragraph,  preventive  and  primary  care  services means the following services rendered to a covered child of an  insured  from  the  date  of birth through the attainment of nineteen years;  (i)  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;  (ii) 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  (iii) 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.  (C) Such coverage required pursuant to subparagraph (A) or (B) of this paragraph shall not be subject to annual deductibles or coinsurance.  (D) Such coverage required pursuant to subparagraph (A) or (B) of this paragraph shall not restrict or eliminate existing coverage provided  by the policy.  (E)  In  addition  to  subparagraph  (A),  (B),  (C)  or  (D)  of this paragraph, every policy that provides hospital, surgical or medical care coverage, except for a grandfathered health plan under subparagraph  (F) of  this  paragraph, shall provide coverage for the following preventive care and screenings for insureds, and such coverage shall not be subject to annual deductibles or coinsurance:  (i)  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;  (ii) 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;  (iii) 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  (iv)  with  respect  to  women,  such  additional  preventive care and screenings not described  in  item  (i)  of  this  subparagraph  and  as provided  for  in  comprehensive  guidelines  supported  by  the  health resources and services administration.  (v) all FDA-approved contraceptive drugs, devices, and other products, including  all  over-the-counter  contraceptive  drugs,   devices,   and products as prescribed or as otherwise authorized under state or federal law;  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;  patient   education   and counseling  on  contraception;  and  follow-up  services  related to the drugs, devices, products, and  procedures  covered  under  this  clause, including,  but  not  limited to, management of side effects, counseling for continued adherence, and device insertion  and  removal.  Except  as otherwise  authorized under this clause, a contract shall not impose any restrictions or delays on  the  coverage  required  under  this  clause. However,  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  clause.  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. (a) 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.  (b) 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. (c) This coverage must allow for the dispensing of up to twelve months worth of a contraceptive at one time. (d) For the purposes of this clause, "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.  (F)  For purposes of this paragraph, "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).  (18) (A) Every policy 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 for such covered person undergoing a lymph  node  dissection or  a  lumpectomy  for  the  treatment  of breast cancer or a mastectomy covered  by  the  policy.  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 policyholder prior to  inception of such policy and annually thereafter.  (B)  An  insurer  providing  coverage  under  this  paragraph  and any participating entity through which the insurer  offers  health  services shall not:  (i) 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 paragraph;  (ii) provide incentives (monetary or otherwise) to encourage a covered person  to accept less than the minimum protections available under this paragraph;  (iii) 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;  (iv)  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  (v)  restrict  coverage  for any portion of a period within a hospital length of stay required under  this  paragraph  in  a  manner  which  is inconsistent  with  the  coverage  provided for any preceding portion of such stay.  (C) The prohibitions in subparagraph (B) of this paragraph shall be in addition to the  provisions  of  sections  three  thousand  two  hundred thirty-one and three thousand two hundred thirty-two of this article and nothing  in  this subparagraph shall be construed to suspend, supersede, amend or otherwise modify such sections.  (19) (A) Every  policy  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  policy  that  requires,  or  provides  financial incentives for, the insured to receive covered services from health care providers  participating  in  a  provider network maintained by or under contract with the insurer, the  policy  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  insured  beyond  what  such  insured  would have paid for services from a participating appropriate specialist.  Provided  however that  nothing herein shall impair an insured's rights (if any) under the policy 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  policy  for  services provided  by  non-participating  providers. The insurer 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  policy  that  does  not  provide  financial incentives  for,  and  does  not require, the insured to receive covered services from health care providers participating in a provider  network maintained  by  or  under  contract  with  the insurer, the policy shall include coverage for a second medical opinion from a  specialist  at  no additional  cost  to the insured beyond what the insured would have paid for comparable services covered under the policy.  (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 policy, and, where applicable, consistent with the provisions of clauses (i) and (ii) of this subparagraph.   Nothing  in  this  paragraph  shall eliminate or diminish an insurer's obligation to comply with the provisions of section four thousand  eight hundred  four  of  this  chapter where applicable. Written notice of the availability of such coverage shall be  delivered  to  the  policyholder prior to the inception of such policy and annually thereafter.  (B)  An  insurer  providing  coverage  under  this  paragraph  and any participating entity through which the insurer  offers  health  services shall not:  (i) 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 paragraph;  (ii) provide incentives (monetary or otherwise) to encourage a covered person  to accept less than the minimum protections available under this paragraph;  (iii) 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; or  (iv)  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.  (C) The prohibitions in subparagraph (B) of this paragraph shall be in addition  to  the  provisions  of  sections  three  thousand two hundred thirty-one and three thousand two hundred thirty-two of this article and nothing in this subparagraph shall be construed to  suspend,  supersede, amend or otherwise modify such sections.  (20)  (A)  Every  policy  which  provides  medical,  major medical, or similar comprehensive-type coverage shall provide the following coverage for  breast  reconstruction  surgery  after  a  mastectomy  or   partial mastectomy:  (i) all stages of reconstruction of the breast on which the mastectomy or partial mastectomy has been performed; and  (ii)  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 and 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 policyholder prior to inception of such policy and annually thereafter.  (B) An  insurer  providing  coverage  under  this  paragraph  and  any participating  entity  through  which the insurer offers health services shall not:  (i) 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 paragraph;  (ii) provide incentives (monetary or otherwise) to encourage a covered person to accept less than the minimum protections available under  this paragraph;  (iii)  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;  (iv) 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  (v) restrict coverage for any portion of a period  within  a  hospital length  of  stay  required  under  this  paragraph  in a manner which is inconsistent with the coverage provided for  any  preceding  portion  of such stay.  (C)  The  prohibitions  in  this paragraph shall be in addition to the provisions of sections three thousand two hundred thirty-one  and  three thousand  two  hundred  thirty-two  of  this article and nothing in this paragraph shall be construed to suspend, supersede, amend  or  otherwise modify such sections.   * (21)  Every  policy  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 par (21)'s   * (21)(A) Every policy which is a "managed care product" as defined in subparagraph  (D) of this paragraph that provides coverage for physician services in a physician's office, and every policy which is  a  "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.  (C) Every policy which includes coverage for physician services  in  a physician's  office,  and  every  policy which provides major medical or similar comprehensive-type coverage, other than a "managed care product" as defined in subparagraph (D) of this paragraph, 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 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.  (D) For purposes of this paragraph, a  "managed  care  product"  shall mean  a policy which requires that medical or other health care services covered under  the  policy,  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  insurer'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 insurer's  managed care provider network, in order for the insured to be entitled to the maximum reimbursement under the contract.  (E) The coverage required by this paragraph shall not be  abridged  by any regulation promulgated by the superintendent.   * NB There are 2 par (21)'s  (22)  No  policy  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 paragraph shall be provided subject to the terms and conditions generally applicable  to  other  benefits  provided under the policy.  (23)   If  a  policy  provides  for  reimbursement  for  physical  and occupational therapy  service  which  is  within  the  lawful  scope  of practice  of  a  duly  licensed  physical  or occupational therapist, an insured shall be entitled to reimbursement for such service whether  the said  service  is  performed  by  a physician or through a duly licensed physical or  occupational  therapist,  provided  however,  that  nothing contained  herein  shall be construed to impair any terms of such policy  including appropriate utilization review and the requirement  that  said service  be  performed  pursuant  to  a  medical  order, or a similar or related service of a physician.  (24)(A)   Every   policy  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.  (B) 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  paragraph, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms  of the policy.  (C)   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.  (D)  The  provisions  of  this  paragraph shall have no application to transfers of patients between hospitals or health care facilities by  an ambulance service as described in subparagraph (A) of this paragraph.  (E) As used in this paragraph:  (i)   "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 paragraph, 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.  (ii) "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.  (25) (A) Every policy which provides coverage for hospital or surgical coverage  shall  not  exclude  coverage  for  screening,  diagnosis  and treatment  of  medical conditions otherwise covered by the policy solely because the treatment is provided to diagnose or treat  autism  spectrum disorder.  (B)  Every  policy  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 policy 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 policy. This paragraph  shall  not  be  construed  as limiting  the  benefits  that  are  otherwise available to an individual under the policy, provided however that such policy  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.  (C) For purposes of this paragraph:  (i) "autism  spectrum  disorder"  means  any  pervasive  developmental disorder  as  defined  in  the most recent edition of the diagnostic and statistical manual of mental disorders.  (ii) "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.  (iii) "behavioral health treatment"  means  counseling  and  treatment programs,  when  provided  by  a licensed provider, and applied behavior analysis, when provided by a person  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.  (iv)  "diagnosis  of  autism  spectrum  disorder"  means  assessments, evaluations, or tests to  diagnose  whether  an  individual  has  autism spectrum disorder.  (v)  "pharmacy care" means medications prescribed by a licensed health care provider legally authorized to prescribe under title eight  of  the education law.  (vi) "psychiatric care" means direct or consultative services provided by  a  psychiatrist  licensed  in  the  state  in which the psychiatrist practices.  (vii) "psychological  care"  means  direct  or  consultative  services provided   by  a  psychologist  licensed  in  the  state  in  which  the psychologist practices.  (viii) "therapeutic care"  means  services  provided  by  licensed  or certified speech therapists, occupational therapists, social workers, or physical therapists.  (ix)  "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:  (1) behavioral health treatment;  (2) psychiatric care;  (3) psychological care;  (4) medical care provided by a licensed health care provider;  (5)  therapeutic  care,  including  therapeutic  care  which is deemed habilitative or nonrestorative, in the event that  the  policy  provides coverage for therapeutic care; and  (6)  pharmacy  care in the event that the policy provides coverage for prescription drugs.  (D) 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.  (E) Nothing in  this  paragraph  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.  (F) Nothing in  this  paragraph  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.  (G) Nothing in this paragraph shall be construed to prevent  a  policy from providing services through a network of participating providers who shall  meet  certain  requirements for participation, including provider credentialing.  (H)  Coverage  under  this  paragraph  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.  (I) The criteria for medical necessity determinations under the policy with  respect  to  autism  spectrum  disorder  benefits  shall  be  made available  by  the  insurer  to  any  insured,  prospective  insured, or in-network provider upon request.  (J) For purposes of this paragraph:  (i) "financial requirement" means deductible, copayments,  coinsurance and out-of-pocket expenses;  (ii)  "predominant"  means  that  a financial requirement or treatment limitation is the most common or frequent  of  such  type  of  limit  or requirement; and  (iii)   "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 policy.  (K) An insurer shall provide  coverage  under  this  paragraph,  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).  (26)(A) No managed care health insurance policy 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.  (B) No managed care health insurance policy 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.  (C) For purposes of this paragraph, 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.  (D)  For  purposes of this paragraph, a "managed care health insurance policy" is a policy  that  requires  that  services  be  provided  by  a provider participating in the insurer's network in order for the insured to receive the maximum level of reimbursement under the policy.   * (27)  No policy delivered or issued for delivery in this state 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).   * NB There are 2 par (27)'s   * (27)(A)  Every  policy 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:  (i)  The  out-of-network  provider  is  duly  licensed to practice and authorized to provide such treatment;  (ii) The out-of-network provider is located outside the  service  area of the insurer;  (iii)  The in-network healthcare provider treating the insured for the condition issues a written order for dialysis treatment stating that  in his or her opinion such treatment is necessary;  (iv) The insured has notified, in writing, the insurer 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  clause  (iii)  of  this  subparagraph. In the event the insured must travel on sudden notice due to family or other emergency, shorter notice may be permitted, provided that the insurer has  reasonable  opportunity to review the travel and treatment plans of the insured;  (v)  The  insurer  shall  have  the  right to pre-approve the dialysis treatment and schedule; and  (vi) Such coverage is limited to no greater  than  ten  out-of-network treatments in a calendar year.  (B)  Where  coverage for out-of-network dialysis treatment is provided pursuant to subparagraph (A) of this  paragraph,  no  insurer  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 insurer shall be the responsibility of the insured receiving the out-of-network services.  (C) Such coverage of  out-of-network  dialysis  services  required  by subparagraph  (A)  of  this  paragraph 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.   * NB There are 2 par (27)'s   * (28)  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  paragraph, 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 verify the prescription.   * NB There are 2 par (28)'s   * (28) Any policy that provides coverage for prescription drugs  shall permit  each  insured  to  fill  any  covered  prescription  that may be obtained at a network  participating  mail  order  or  other  non-retail pharmacy,  at  the insured'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 insurer has established for the network participating mail order or other  non-retail  pharmacy.  In such  a  case,  the  policy  shall  not impose a co-payment fee or other condition on any insured who elects to purchase prescription drugs  from a network participating non-mail order retail pharmacy which is not also imposed   on   insureds  electing  to  purchase  drugs  from  a  network participating mail order or other non-retail pharmacy.   * NB There are 2 par (28)'s  (29) Every individual policy 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.    * (30)(A) Every  policy  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 policy.  (B)  Coverage  provided  under  this  paragraph  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.  (C)  Coverage  provided  under this paragraph 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 policy.  (D) This subparagraph 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  insurer's provider  network.  Coverage  provided under this paragraph shall not be subject to preauthorization.  Coverage  provided  under  this  paragraph 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  insurer  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 insurer 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  insurer  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 insurer  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 insurer which is designated  by  the  office  of  alcoholism  and substance  abuse  services.  Prior  to  discharge,  the  facility  shall indicate to the insurer whether services included in the discharge  plan are  secured  or  determined to be reasonably available. Any utilization review of treatment provided  under  this  subparagraph  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 insurer 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  insurer  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 subparagraph other than any copayment, coinsurance, or deductible otherwise required under the policy.  (E)  An  insurer  shall  make  available  to  any insured, prospective insured, or in-network provider, upon request, the criteria for  medical necessity  determinations  under  the  policy  with respect to inpatient substance use disorder benefits.  (F) For purposes of this paragraph:  (i) "financial requirement" means deductible, copayments,  coinsurance and out-of-pocket expenses;  (ii)  "predominant"  means  that  a financial requirement or treatment limitation is the most common or frequent  of  such  type  of  limit  or requirement;  (iii)   "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 policy; and  (iv) "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.  (G) An insurer shall provide  coverage  under  this  paragraph,  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).   * NB There are 2 par (30)'s   * (30)  Every  policy  that  provides  medical  coverage that includes coverage for physician services in a physician's office and every policy that 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 paragraph 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 three thousand two hundred seventeen-i of this article.   * NB There are 2 par (30)'s  (31) (A) Every policy 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 policy.  (B) Coverage under this paragraph 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.  (C)  Coverage  provided  under this paragraph 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 policy.  (D)  A  policy  providing coverage for substance use disorder services pursuant to this paragraph shall provide up to twenty outpatient  visits per  policy  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  policy  pursuant  to  this  paragraph.  The coverage  required by this paragraph shall include treatment as a family member pursuant to such family member's own policy provided such  family member:  (i)  does not exceed the allowable number of family visits provided by the applicable policy pursuant to this paragraph; and  (ii) is otherwise entitled to coverage pursuant to this paragraph  and such family member's applicable policy.  (E) This subparagraph 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 insurer's provider network. Coverage provided under this paragraph  shall  not  be  subject  to  preauthorization.  Coverage provided  under this paragraph 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 insurer 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  insurer 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  insurer  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  subparagraph 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  insurer  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 insurer  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 subparagraph other than any copayment, coinsurance,  or  deductible  otherwise  required  under  the policy.  (F) The criteria for medical necessity determinations under the policy with respect to outpatient substance use disorder benefits shall be made available  by  the  insurer  to  any  insured,  prospective  insured, or in-network provider upon request.  (G) For purposes of this paragraph:  (i)  "financial requirement" means deductible, copayments, coinsurance and out-of-pocket expenses;  (ii) "predominant" means that a  financial  requirement  or  treatment limitation  is  the  most  common  or  frequent of such type of limit or requirement;  (iii)  "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 policy; and  (iv)  "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.  (H)  An  insurer  shall  provide  coverage  under this paragraph, 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).  (I) This subparagraph 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 insurer's provider network.  Benefits for  care  in  a  crisis  stabilization  center  shall not be subject to preauthorization. All treatment provided under this subparagraph 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 subparagraph other than any copayment, coinsurance, or deductible otherwise required under the policy.  (31-a)  (A)  No policy that provides medical, major medical or similar comprehensive-type coverage and provides coverage for prescription drugs for medication for the treatment  of  a  substance  use  disorder  shall require  prior  authorization for an initial or renewal prescription for all  buprenorphine  products,  methadone  or  long   acting   injectable naltrexone  for  detoxification  or maintenance treatment of a substance use disorder except where otherwise prohibited by law.  (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.  (32)  No  policy  delivered  or issued for delivery in this state 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: (A) the registered nurse  first assistant is certified in operating room nursing; (B) the services are within the scope of  practice  of  a  non-physician  surgical  first assistant;  and  (C)  the  terms  and conditions of the policy otherwise provide  for  the  coverage  of  the services. Nothing in this paragraph 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.   * (33)  Every  policy  delivered  or issued for delivery in this state 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 par (33)'s   * (33) Whenever in this section an  insurer  is  required  to  provide benefits with no coinsurance or deductible, the requirement only applies with  respect  to  participating  providers in the insurer's network, or with respect to non-participating providers, if  the  insurer  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 insured pursuant to subsection (d) of section three thousand two hundred seventeen-d of this article.   * NB There are 2 par (33)'s   * (34) Health care forensic examinations performed pursuant to section twenty-eight hundred five-i of the public health law covered  under  the policy shall not be subject to annual deductibles or coinsurance.   * NB There are 2 par (34)'s   * (34)  Every  policy 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.   * NB There are 2 par (34)'s  (35)  (A)  Every policy delivered or issued for delivery in this state that provides coverage for  inpatient  hospital  care  or  coverage  for physician   services  shall  provide  coverage  for  the  diagnosis  and treatment of mental health conditions as follows:  (i) where the policy provides coverage for  inpatient  hospital  care, benefits  for inpatient care in a hospital as defined by subdivision ten of section 1.03 of the mental hygiene law and  benefits  for  outpatient 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 care  provided in other states, to similarly licensed or  certified  hospitals or facilities; and  (ii)  where  the  policy  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 subparagraph  (D)  of  paragraph  four  of subsection  (1) of section three thousand two hundred twenty-one of this article, a nurse practitioner licensed to practice in this state,  or  a professional  corporation  or  university  faculty  practice corporation thereof.  (B) Coverage required by this  paragraph  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 policy.  (C)   Coverage   under   this  paragraph  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 policy.  (D) The criteria for medical necessity determinations under the policy with respect to mental health benefits shall be made  available  by  the insurer to any insured, prospective insured, or in-network provider upon request.  (E) For purposes of this paragraph:  (i)  "financial requirement" means deductible, copayments, coinsurance and out-of-pocket expenses;  (ii) "predominant" means that a  financial  requirement  or  treatment limitation  is  the  most  common  or  frequent of such type of limit or requirement;  (iii)  "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 policy; and  (iv)  "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.  (F)  An  insurer  shall  provide  coverage  under this paragraph, 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).  (G) This subparagraph shall apply to hospitals in this state that  are licensed  by  the  office of mental health that are participating in the insurer's provider network.  Where  the  policy  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  subparagraph  shall  also  not  be  subject  to  concurrent utilization review during the  first  fourteen  days  of  the  inpatient admission,  provided  the  facility  notifies  the  insurer  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 insurer to ensure that the facility is using the  evidence-based  and  peer  reviewed  clinical review  criteria utilized by the insurer 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   subparagraph   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  subparagraph  other  than  any  copayment,  coinsurance, or deductible otherwise required under the policy.  (H) This subparagraph 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 insurer's provider network.  Benefits for  care  in  a  crisis  stabilization  center  shall not be subject to preauthorization. All treatment provided under this subparagraph 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 subparagraph other than any copayment, coinsurance, or deductible otherwise required under the policy.  (j)  (1)  Every  insurer  issuing  a  policy  of  accident  and health insurance for  delivery  in  this  state  which  provides  coverage  for in-patient  hospital  care  must make available and, if requested by the policyholder, provide coverage for care in a nursing home. Such coverage shall be made available at the inception of all new policies  and,  with respect  to  all  other  policies  at any anniversary date of the policy subject to evidence of insurability.  (A) In this paragraph nursing home care means 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 twenty-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 admission, 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, may 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.  (B)  Ambulatory care means care in hospital out-patient facilities, as a hospital is defined in section twenty-eight hundred one of the  public health  law  or  subchapter XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq,  and  physicians'  offices.  Ambulatory  care  in hospital  out-patient  facilities  means services for diagnostic X-rays, laboratory and pathological examinations, physical 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 be provided for physical therapy 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.  Ambulatory  care  in physicians'  offices  means  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 related to and necessary for the treatment or diagnosis of the patient's illness or injury, and ordered by a  physician.  Such  coverage  shall  be  made available  at the inception of all new policies and, with respect to all other policies, at  any  anniversary  date  of  the  policy  subject  to evidence of insurability.  (2)  Every  insurer  issuing a policy of accident and health insurance for delivery in this state which provides coverage supplementing part  A and  part  B  of subchapter XVIII of the federal Social Security Act, 42 U.S.C.  §§ 1395 et seq, must make available and,  if  requested  by  the insured,  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 case visits per policy year. Such coverage shall be provided pursuant to  regulations  prescribed  by the superintendent.  (3)  Consistent  with  federal  law, every insurer issuing a policy of accident and health insurance for delivery in this state 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  the insured, 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 where 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 policies and,  with  respect  to  all  other policies, at each anniversary date of the policy.  (A)  Coverage  shall  be subject to a copayment of twenty-five dollars per day.  (B) Brochures  describing  such  coverage  must  be  provided  to  all applicants  at  the  time  of  application  for  all  new  policies  and thereafter on each anniversary date of the policy, and with  respect  to all other policies annually at each anniversary date of the policy. Such brochures  must  be  approved by the superintendent in consultation with the commissioner of health.  (C) The commensurate rate for the coverage must  be  approved  by  the superintendent.  (D)  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.  (k)  Any  person,  partnership  or corporation willfully violating any provision of this section, regulation or  order  of  the  superintendent made in accordance with this section, shall forfeit to the people of the state  a  sum not to exceed one hundred dollars for each such violation. The superintendent may also suspend or revoke the license of an  insurer or agent or broker for any such willful violation.  (l)  An  insurer  shall  not  offer  individual  hospital,  medical or surgical  expense  insurance  policies  unless  the  policies  meet  the  requirements  of  subsection  (b) of section four thousand three hundred twenty-eight of this chapter. Such policies that are offered within  the health  benefit  exchange  established by this state also shall meet any requirements established by the health benefit exchange.  (m)  An  insurer  shall  not be required to offer the policyholder any benefits that must be made available pursuant to  this  section  if  the benefits  must  be  covered as essential health benefits. For any policy issued within the health benefit exchange established by this state,  an insurer  shall  not  be  required to offer the policyholder any benefits that must be made available pursuant to this section.  For  purposes  of this  subsection, "essential health benefits" shall have the meaning set forth  in  subsection  (a)  of  section  three  thousand   two   hundred seventeen-i of this article.