NY Ins L § 3221 (2021)
2021 New York Laws ISC - Insurance Article 32 - Insurance Contracts - Life, Accident and Health, Annuities 3221 - Group or Blanket Accident and Health Insurance Policies; Standard Provisions.

§  3221.  Group  or  blanket  accident  and health insurance policies; standard provisions. (a) No policy of  group  or  blanket  accident  and health  insurance shall, except as provided in subsection (d) hereof, be delivered or issued for delivery in this state  unless  it  contains  in substance the following provisions or provisions which in the opinion of the   superintendent   are   more  favorable  to  the  holders  of  such certificates or not less favorable to the holders of  such  certificates and   more  favorable  to  policyholders,  provided  however,  that  the provisions set forth in paragraphs six and thirteen of  this  subsection shall  not  be  applicable  to  any  such  policy  which  is issued to a policyholder in accordance with subparagraph (E)  of  paragraph  one  of subsection  (c) of section four thousand two hundred thirty-five of this chapter:  (1) (A) No statement made  by  the  person  insured  shall  avoid  the insurance  or  reduce  benefits thereunder unless contained in a written instrument signed by the person insured.  (B) All statements contained in any such written instrument  shall  be deemed representations and not warranties.  (2)  That  no agent has authority to change the policy or waive any of its provisions and that no change in the policy shall  be  valid  unless approved  by  an  officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer.  (3) That all new employees or new members in the classes eligible  for insurance must be added to such class for which they are eligible.  (4)  That  all  premiums due under the policy shall be remitted by the employer or employers of the persons insured or by some other designated person acting on behalf of the association  or  group  insured,  to  the insurer  on or before the due date thereof, with such period of grace as may be specified therein.  (5) The conditions under which the insurer may decline  to  renew  the policy.  (6)  That  the insurer shall issue either to the employer or person in whose name such policy is issued, for delivery to  each  member  of  the insured  group,  a certificate setting forth in summary form a statement of the essential features of the insurance coverage and in substance the following provisions of this subsection.  (7) The ages,  to  which  the  insurance  provided  therein  shall  be limited;  and  the ages, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages.  (8) That 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. Failure to give notice within such time shall not invalidate or reduce any claim if it shall be shown not  to  have  been  reasonably possible  to  give  such notice and that notice was given as soon as was reasonably possible.  (9) That in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within  thirty  days after  the  commencement  of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as  the  insurer  may reasonably  require,  and  that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer  within  one hundred twenty days after the date of such loss. Failure to furnish such proof  within  such  time shall not invalidate or reduce any claim if it shall be shown not to have been  reasonably  possible  to  furnish  such  proof  within  such  time,  provided such proof was furnished as soon as reasonably possible.  (10)  That  the  insurer will furnish to the person making claim or to the policyholder for delivery to such person such forms as  are  usually furnished  by  it  for  filing  proof  of  loss.  If  such forms are not furnished before the  expiration  of  fifteen  days  after  the  insurer receives  notice  of  any claim under the policy, the person making such claim shall be deemed to have complied  with  the  requirements  of  the policy  as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the  occurrence, character and extent of the loss for which claim is made.  (11)  That the insurer shall have the right and opportunity to examine the person of the individual for whom claim is made when and so often as it may reasonably require during the pendency of claim under the  policy and  also  the right and opportunity to make an autopsy in case of death where it is not prohibited by law.  (12) That benefits payable under the policy other  than  benefits  for loss  of  time will be payable not more than sixty days after receipt of proof, and that, subject to due  proof  of  loss  all  accrued  benefits payable  under  the  policy  for  loss  of  time  will  be paid not less frequently than monthly during the continuance of the period  for  which the  insurer  is  liable,  and  that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof.  (13) That indemnity for loss of life of  the  insured  is  payable  in accordance  with  subsection  (e)  of  section four thousand two hundred thirty-five of this chapter; and  that  all  other  indemnities  of  the policy  are  payable to the insured, except as may be otherwise provided in accordance with  such  subsection;  and  that  if  a  beneficiary  is designated,  the  consent  of  the beneficiary shall not be requisite to change of beneficiary,  or  to  any  other  changes  in  the  policy  or certificate, except as may be specifically provided by the policy.  (14) That no action at law or in equity shall be brought to recover on the policy prior to the expiration of sixty days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought after the expiration of two years following the time such proof of loss is required by the policy.  (15)  Any policy and certificate, 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 OR CERTIFICATE 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."  (16) 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).  (b) No such policy shall be delivered or issued for delivery  in  this state  unless  a  schedule  of the premium rates pertaining to such form shall have been filed with the superintendent.  (c) Any portion of any such policy, which purports, by reason  of  the circumstances  under  which  a  loss is incurred, to reduce any benefits promised thereunder to an amount less than that provided  for  the  same loss  occurring  under ordinary circumstances, shall be printed, in such policy  and in each certificate issued thereunder, in bold face type and with greater prominence than any other  portion  of  the  text  of  such policy  or  certificate; and all other exceptions of the policy shall be printed in the policy and in the certificate, with the  same  prominence as  the  benefits  to  which they apply. If any such policy contains any provision which affects the liability of the  insurer,  on  the  grounds stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of section three thousand two hundred sixteen of this  article,  then  such provision  shall  be contained in the policy and certificate in the form set forth in such section.  (d) (1) The superintendent may approve any form of certificate  to  be issued  under  a blanket accident and health insurance policy as defined in section four thousand two hundred thirty-seven of this chapter, which omits or modifies any of the provisions hereinbefore  required,  if  the superintendent  deems  such  omission  or  modification suitable for the character of such insurance  and  not  unjust  to  the  persons  insured thereunder.  Certificates  issued  under a policy or contract of student accident and health insurance as defined in section three  thousand  two hundred forty of this article shall comply with such section.  (2)  The superintendent may approve any form of group insurance policy providing disability benefits to be issued pursuant to article  nine  of the  workers'  compensation  law  which  omits  or  modifies  any of the provisions hereinbefore required, if such omission  or  modification  is not  inconsistent  with the provisions of such article nine and he deems such omission  or  modification  suitable  for  the  character  of  such insurance and not unjust to the persons insured thereunder.  (3)  The  superintendent  may also approve any form of group insurance policy  to  be  issued  to  a  social  services  district  pursuant   to subdivision  two  of  section  three hundred sixty-seven-a of the social services law, which omits or modifies any of the provisions hereinbefore required, if he deems such omission or  modification  suitable  for  the character of such insurance.  (e) (1) A group policy providing hospital, medical or surgical expense insurance  for  other  than  specific  diseases  or accident only, shall provide that if the insurance on an employee or member insured under the group policy ceases because of  termination  of  (A)  employment  or  of membership  in  the  class  or  classes  eligible for coverage under the policy or  (B)  the  policy,  for  any  reason  whatsoever,  unless  the policyholder  has  replaced the group policy with similar and continuous coverage for the  same  group  whether  insured  or  self-insured,  such employee  or member who has been insured under the group policy shall be entitled to have issued to the insured by the insurer  without  evidence of  insurability  upon application made to the insurer within sixty days after such termination, and payment of the quarterly, or, at the  option of  the  employee  or  member, a less frequent premium applicable to the form and amount of insurance, an individual  policy  of  insurance.  The insurer may, at its option elect to provide the insurance coverage under a  group  insurance  policy,  delivered  in  this  state, in lieu of the issuance of a converted individual policy of insurance. Such  individual policy,  or group policy, as the case may be is hereafter referred to as the converted policy. The benefits provided under the  converted  policy shall  be  those  required by subsection (f) and (g) of this section, in the event of termination of the converted  group  policy  of  insurance,  each  insured thereunder shall have a right of conversion to a converted individual policy of insurance.  (2)  The  insurer  shall  not  be required to issue a converted policy covering any person if such person is covered for  similar  benefits  by another  hospital  or  surgical  or  medical expense insurance policy or hospital or medical service subscriber contract or medical  practice  or other  prepayment plan or by any other plan or program or such person is eligible for similar benefits, whether or not  covered  therefor,  under any arrangement of coverage for individuals in a group, other than under the  converted  policy,  whether  on  an  insured  or uninsured basis or similar benefits are provided for or available to such  person  pursuant to any statute; and the benefits provided or available under any of such sources  which  together  with the benefits provided under the converted policy  would  result  in  overinsurance  or  duplication  of   benefits according to standards on file with the superintendent.  (3)  The  converted  policy  shall,  at  the option of the employee or member, provide identical coverage for the dependents of  such  employee or  member  who  were covered under the group policy. Provided, however, that if the employee or member chooses the option of dependent  coverage then  dependents  acquired after the permitted time to convert stated in paragraph one of this subsection shall be added to the converted  family policy  in  accordance  with the provisions of subsection (c) of section thirty-two  hundred  sixteen  of  this  article  and   any   regulations promulgated  or  guidelines  issued by the superintendent. The effective date of the individual's coverage under the converted  policy  shall  be the  date  of  the  termination  of the individual's insurance under the group policy as to those persons covered under the group policy.  (4) If delivery of an  individual  converted  policy  is  to  be  made outside  this  state,  it may be on such form as the insurer may then be offering for such conversion in the jurisdiction where such delivery  is to be made.  (5) The conversion provision shall also be available upon the death of the  employee or member, to the surviving spouse with respect to such of the spouse and children as are then covered by  the  group  policy,  and shall  be  available  to a child solely with respect to himself upon his attaining the limiting age of coverage  under  the  group  policy  while covered  as  a dependent thereunder. It shall also be available upon the divorce or annulment of the marriage of the employee or member,  to  the former spouse of such employee or member.  (6)  (A) Each certificate holder shall be given written notice of such conversion privilege and its duration  within  fifteen  days  before  or after  the  date of termination of group coverage, provided that if such notice be given more than fifteen days but less than ninety  days  after the  date  of  termination  of  group coverage, the time allowed for the exercise  of  such  privilege  of  conversion  shall  be  extended   for forty-five  days  after the giving of such notice. If such notice be not given within  ninety  days  after  the  date  of  termination  of  group coverage, the time allowed for the exercise of such conversion privilege shall expire at the end of such ninety days.  (B) Written notice by the policyholder given to the certificate holder or  mailed  to  the  certificate holder's last known address, or written notice by the insurer be sent by first class  mail  to  the  certificate holder at the last address furnished to the insurer by the policyholder, shall  be  deemed full compliance with the provisions of this subsection for the giving of notice.  (C) A group contract issued by an insurer may contain a  provision  to the  effect  that  notice  of such conversion privilege and its duration  shall be given by the  policyholder  to  each  certificate  holder  upon termination of his group coverage.  (7)  In  addition  to  the right of conversion herein, the employee or member insured under the policy shall at his option, as  an  alternative to  conversion,  be  entitled  to  have his coverage continued under the group policy in accordance with the conditions and limitations contained in subsection (m) of this section, and have issued at  the  end  of  the period  of  continuation  an individual conversion policy subject to the terms of this subsection. The effective date for the  conversion  policy shall  be the day following the termination of insurance under the group policy, or if there is a continuation of coverage, on the day  following the  end  of  the period of continuation. Notwithstanding the foregoing, the superintendent may require conversion or continuation  of  insurance under  conditions  as  set  forth  in  a regulation for insureds under a policy issued in accordance with subparagraph (E) of  paragraph  one  of subsection  (c) of section four thousand two hundred thirty-five of this chapter.  (8) For purposes  of  this  subsection,  the  term  "dependent"  shall include  a child as described in subsection (f) of section four thousand two hundred thirty-five of this chapter.  (f) If the group insurance policy insures the employee or  member  for hospital,  medical  or  surgical  expense  insurance,  or  if  the group insurance policy insures the employee or member  for  major  medical  or similar comprehensive-type coverage, then the conversion privilege shall entitle  the  employee  or  member  to obtain coverage under a converted policy providing, at the insured's option, coverage under any one of the plans described in subsection (g) of this section on an expense incurred basis.  (g) For conversion purposes, an insurer shall offer to the employee or member a policy 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. 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 subsection and subsections (e) and  (f)  of  this  section  through  the offering  of  policies  that  comply  with  this  subsection  by another insurer, corporation  or  health  maintenance  organization  within  the insurer's  holding company system, as defined in article fifteen of this chapter.  (h) Every small group policy or association group policy delivered  or issued  for  delivery in this state that provides coverage for hospital, medical or surgical expense insurance and is not a grandfathered  health plan  shall  provide coverage for the essential health benefits package. For purposes of this subsection:  (1) "essential health benefits package" shall  have  the  meaning  set forth in paragraph three of subsection (e) of section three thousand two hundred seventeen-i of this article;  (2)  "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);  (3)  "small  group" means a group of one hundred or fewer employees or members exclusive of spouses and dependents; and  (4) "association group" means a group defined  in  subparagraphs  (B), (D),  (H), (K), (L) or (M) of paragraph one of subsection (c) of section four thousand two hundred thirty-five of this chapter, provided that:  (A) the group includes one or more individual members; or  (B)  the  group  includes one or more member employers or other member groups that are small groups.  (i) 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 pursuant to subsection (h) of this section. 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.  (j)  No policy of group or blanket accident and health insurance shall be issued as excess coverage for volunteer firefighters over  and  above the  coverage  provided  for  pursuant  to  the  volunteer firefighters' benefit law unless such excess policy provides for each of the types  of coverages  set forth in subdivision one of section five of such law. Any excess policy which does not contain such provisions shall be  construed as if such coverages were embodied therein.  (k)  (1)  (A)  Every  group policy delivered or issued for delivery in this state which provides coverage for in-patient  hospital  care  shall provide  coverage  for home care to residents in this state, except that this provision shall not apply to a policy which covers persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state. Such home care coverage shall be included at the inception of all new policies and, with respect to all other policies, added  at  any anniversary date of the policy subject to evidence of insurability.  (B)  Such  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.  (C)  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.  (D) 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 subchapter XVIII of  the  federal  Social  Security  Act,  42 U.S.C. §§ 1395 et seq.  (E)  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.  (2)  (A)  Every insurer issuing a group policy delivered or issued for delivery in this state which provides coverage for  in-patient  hospital care shall include coverage for preadmission tests performed in hospital facilities  prior to scheduled surgery, except that this provision shall not apply to a policy which covers persons employed  in  more  than  one state  or  the  benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state.  (B) Such  policy  shall  provide  benefits  for  tests  ordered  by  a physician  which  are  performed  in  the  out-patient  facilities  of a hospital as a planned preliminary to admission  of  the  patient  as  an in-patient for surgery in the same hospital, provided that:  (i)  tests  are  necessary  for  and consistent with the diagnosis and treatment of the condition for which surgery is to be performed;  (ii) reservations for a hospital bed and for an  operating  room  were made prior to the performance of the tests;  (iii)  the  surgery  actually  takes  place  within seven days of such presurgical tests; and  (iv) the patient is physically present at the hospital for the tests.  (3) Every group policy delivered or issued for delivery in this  state which  provides  coverage  for  in-patient  surgical  care shall include coverage for a second surgical opinion by a qualified physician  on  the need for surgery, except that this provision shall not apply to a policy which  covers  persons  employed  in  more than one state or the benefit structure of which was the subject of  collective  bargaining  affecting persons who are employed in more than one state.  (4)  (A)  Every  group policy delivered or issued for delivery in this state that provides coverage for inpatient hospital care  shall  include coverage  for  services  to  treat  an  emergency  condition provided in hospital facilities, except that this provision shall  not  apply  to  a policy  which  covers  persons  employed  in  more than one state or the benefit structure of which was  the  subject  of  collective  bargaining affecting  persons  who  are  employed in more than one state unless the policy otherwise provides coverage for services to  treat  an  emergency condition provided 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)  In  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) In 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)  In  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).  (5)  (A)  (i)  Every  group  or blanket policy delivered or issued for delivery in this state which  provides  hospital,  surgical  or  medical coverage  shall include coverage for maternity care, including hospital, surgical or medical care to the same extent that  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 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.  (6)  (A)  Every  group  policy issued or delivered in this state which provides coverage for hospital  care  shall  not  exclude  coverage  for hospital  care  for  diagnosis  and  treatment  of  correctable  medical conditions otherwise covered by the policy solely  because  the  medical condition results in infertility; provided, however that:  (i)  subject  to the provisions of subparagraph (C) of this paragraph, in no case shall such coverage exclude surgical  or  medical  procedures provided as part of such hospital care which would correct malformation, disease or dysfunction resulting in infertility; and  (ii)  provided,  further  however,  that  subject to the provisions of subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage exclude  diagnostic  tests  and  procedures  provided  as  part  of such hospital care that are necessary to determine infertility  or  that  are necessary  in  connection  with  any  surgical  or medical treatments or prescription  drug  coverage  provided  pursuant  to   this   paragraph, including  such  diagnostic tests and procedures as hysterosalpingogram, hysteroscopy, endometrial biopsy,  laparoscopy,  sono-hysterogram,  post coital tests, testis biopsy, semen analysis, blood tests and ultrasound; and  (iii)  provided,  further  however,  every  such policy which provides coverage for prescription drugs shall  include,  within  such  coverage, coverage  for  prescription  drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility  in accordance with subparagraph (C) of this paragraph.  (B)  Every  group  policy  issued  or  delivered  in  this state which provides coverage for  surgical  and  medical  care  shall  not  exclude coverage  for  surgical  and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by  the  policy  solely because  the medical condition results in infertility; provided, however that:  (i) subject to the provisions of subparagraph (C) of  this  paragraph, in  no  case  shall such coverage exclude surgical or medical procedures which would correct malformation, disease or  dysfunction  resulting  in infertility; and  (ii)  provided,  further  however,  that  subject to the provisions of subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage exclude  diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection  with  any  surgical  or medical  treatments  or  prescription drug coverage provided pursuant to this paragraph,  including  such  diagnostic  tests  and  procedures  as hysterosalpingogram,   hysteroscopy,  endometrial  biopsy,  laparoscopy, sono-hysterogram, post coital  tests,  testis  biopsy,  semen  analysis, blood tests and ultrasound; and  (iii)  provided,  further  however,  every  such policy which provides coverage for prescription drugs shall  include,  within  such  coverage, coverage  for  prescription  drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility  in accordance with subparagraph (C) of this paragraph.  (C)   Coverage  of  diagnostic  and  treatment  procedures,  including prescription drugs, used in the diagnosis and treatment  of  infertility as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be provided in accordance with the provisions of this subparagraph.  (i) Diagnosis and treatment of infertility shall be prescribed as part of a physician's overall plan of care and consistent with the guidelines for coverage as referenced in this subparagraph.  (ii)  Coverage  may  be  subject  to  co-payments,   coinsurance   and deductibles  as  may  be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a  given policy.  (iii) Except as provided in items (vi) and (vii) of this subparagraph, coverage shall not be required to include the diagnosis and treatment of infertility  in  connection  with:  (I)  in  vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian  tube  transfers; (II)   the   reversal  of  elective  sterilizations;  (III)  sex  change procedures; (IV)  cloning;  or  (V)  medical  or  surgical  services  or procedures  that  are  deemed  to  be  experimental  in  accordance with clinical guidelines referenced in item (iv) of this subparagraph.  (iv) The superintendent, in  consultation  with  the  commissioner  of health,   shall   promulgate   regulations  which  shall  stipulate  the guidelines and standards  which  shall  be  used  in  carrying  out  the provisions of this subparagraph, which shall include:  (I)  The  identification of experimental procedures and treatments not covered for the diagnosis and treatment  of  infertility  determined  in accordance  with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine;  (II) The identification of the required training, experience and other standards for health care providers for the provision of procedures  and treatments  for the diagnosis and treatment of infertility determined in accordance with the standards and guidelines established and adopted  by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine; and  (III)  The  determination  of  appropriate  medical  candidates by the treating physician in  accordance  with  the  standards  and  guidelines established  and  adopted  by  the American College of Obstetricians and Gynecologists and/or the American Society for Reproductive Medicine.  (v)(I) For the purposes  of  this  paragraph,  "infertility"  means  a disease  or  condition  characterized  by  the  incapacity to impregnate another person or to conceive, defined by the  failure  to  establish  a clinical  pregnancy  after  twelve months of regular, unprotected sexual intercourse or therapeutic donor insemination, or after  six  months  of regular,   unprotected   sexual   intercourse   or   therapeutic   donor insemination for a female thirty-five years of  age  or  older.  Earlier evaluation  and  treatment  may  be  warranted  based on an individual's medical history or physical findings.  (II) For purposes of this paragraph, "iatrogenic infertility" means an impairment of fertility by surgery,  radiation,  chemotherapy  or  other medical treatment affecting reproductive organs or processes.  (vi)  Coverage  shall  also  include  standard  fertility preservation services when a medical  treatment  may  directly  or  indirectly  cause iatrogenic  infertility to an insured. Coverage may be subject to annual deductibles and coinsurance, including  copayments,  as  may  be  deemed appropriate  by  the  superintendent  and  as  are consistent with those established for other benefits within a given policy.  (vii) Every large group policy delivered or  issued  for  delivery  in this   state   that   provides   medical,   major   medical  or  similar comprehensive-type coverage shall provide coverage for three  cycles  of in-vitro  fertilization  used  in the treatment of infertility. Coverage may  be  subject  to  annual  deductibles  and  coinsurance,   including copayments,  as  may  be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a  given policy.  For  purposes  of this item, a "cycle" is defined as either all treatment that starts when: preparatory medications are administered for  ovarian stimulation for oocyte retrieval with the intent  of  undergoing in-vitro fertilization using a fresh embryo transfer; or medications are administered  for  endometrial preparation with the intent of undergoing in-vitro fertilization using a frozen embryo transfer.  (viii)  No  insurer  providing  coverage  under  this  paragraph shall discriminate based on an insured's expected length of life,  present  of 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.  (D) 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  covered  person  who elects to purchase prescription fertility drugs through a network participating  non-mail  order  retail pharmacy  that  it  does  not impose on any covered person who purchases prescription fertility drugs through a network participating mail  order or  other non-retail pharmacy; provided, however, that the provisions of this section shall not supersede the terms of  a  collective  bargaining agreement  or  apply  to  a  policy  that  is the result of a collective bargaining agreement between an employer and a recognized  or  certified employee organization.  (7)(A)  Every  group  or  blanket accident and health insurance policy issued 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  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.  (C)  This  paragraph  shall not apply to a policy which covers persons employed in more than one state or the benefit structure  of  which  was the  subject of collective bargaining affecting persons employed in more than one state unless such policy is issued under  the  New  York  state health  insurance  plan  established  under  article eleven of the civil service law or issued to or through a local government.  (8) (A) Every group or blanket policy delivered or issued for delivery in this state 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.  (9)(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  an 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  coverage  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.  (10)(A) Every group or blanket policy delivered or issued for delivery in  this  state  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.    * (11) 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 (11)'s   * (11)(A) Every policy which is a "managed care product" as defined in subparagraph  (D) of this paragraph that includes 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 that 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 (11)'s  (12) No policy of group  or  blanket  accident  and  health  insurance delivered or issued for delivery in this state shall exclude coverage of a  health  care service, as defined in paragraph two of such subdivision (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.  (13) Every group or blanket policy delivered or issued for delivery in this  state  that  provides  major medical or similar comprehensive-type coverage  shall  provide  such  coverage  for   bone   mineral   density measurements  or tests, and if such contract otherwise includes coverage for prescription drugs, drugs and devices approved by the  federal  food and  drug administration or generic equivalents as approved substitutes. In determining appropriate coverage provided by subparagraphs  (A),  (B) and   (C)   of   this  paragraph,  the  insurer  or  health  maintenance organization shall adopt standards that  include  the  criteria  of  the federal  Medicare program and the criteria of the national institutes of health for the detection of osteoporosis, provided  that  such  coverage shall be further determined as follows:  (A)  for purposes of subparagraphs (B) and (C) of this paragraph, bone mineral density measurements or tests, drugs and devices  shall  include those  covered  under  the  federal Medicare program as well as those in accordance with the criteria  of  the  national  institutes  of  health, including,   as   consistent   with  such  criteria,  dual-energy  x-ray absorptiometry.  (B) for purposes of subparagraphs (A) and (C) of this paragraph,  bone mineral  density  measurements  or  tests,  drugs  and  devices shall be covered for individuals meeting the criteria under the federal  Medicare program  or  the criteria of the national institutes of health; provided that,  to  the  extent  consistent  with  such   criteria,   individuals qualifying for coverage shall at a minimum, include individuals:  (i)  previously  diagnosed  as  having osteoporosis or having a family history of osteoporosis; or  (ii) with symptoms or conditions indicative of the  presence,  or  the significant risk, of osteoporosis; or  (iii)  on  a  prescribed  drug  regimen  posing  a significant risk of osteoporosis; or  (iv) with lifestyle factors to such a degree as posing  a  significant risk of osteoporosis; or  (v)  with  such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis.  (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 group or  blanket  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  items  or services for bone mineral density and such coverage shall not be subject to annual deductibles or coinsurance:  (i) evidence-based items or services for  bone  mineral  density  that have  in effect a rating of 'A' or 'B' in the current recommendations of the United States preventive services task force; and  (ii) with respect  to  women,  such  additional  preventive  care  and screenings  for  bone  mineral density 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).  (14)  No  group  or blanket policy delivered or issued for delivery in this  state  which  provides   medical,   major   medical   or   similar comprehensive-type  coverage shall exclude coverage for services covered under such policy when provided  by  a  comprehensive  care  center  for eating  disorders  pursuant to article thirty of the mental hygiene law; provided, however, that reimbursement under  such  policy  for  services provided  through  such  comprehensive care centers shall, to the extent possible and practicable, be structured in a manner  to  facilitate  the individualized,  comprehensive  and  integrated plans of care which such centers' network of practitioners and providers are required to provide.  (15)(A) No group or blanket 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  group  or  blanket  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.  (16)(A)  Every  group  or  blanket  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.  (17)  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 verity the prescription.  (18) Every group or  blanket  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.  (19)  Every  group  or  blanket  accident  and health insurance policy delivered or issued for delivery in this  state  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.  (20)  No  group  or blanket 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.  (21) Every group or blanket 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.  (l) (1) Every insurer delivering a group policy  or  issuing  a  group policy  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 policyholder, provide coverage  of  supplemental  home  care  visits beyond  those  provided  by  part A and part B, sufficient to produce an aggregate coverage of three hundred  sixty-five  home  care  visits  per policy  year.  Such  coverage  shall be provided pursuant to regulations prescribed by the superintendent. Written notice of the availability  of such  coverage shall be delivered to the policyholder prior to inception of such group policy and annually thereafter, except  that  this  notice shall  not  be  required  where  a  policy  covers  two  hundred or more employees or where the benefit structure was the subject  of  collective bargaining affecting persons who are employed in more than one state.  (2)  (A)  Every  insurer  delivering a group policy or issuing a group policy  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.  Written notice  of  the  availability of such coverage shall be delivered to the policyholder prior to  inception  of  such  group  policy  and  annually thereafter, except that this notice shall not be required where a policy covers  two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are  employed in more than one state.  (B)  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.  (C) In this paragraph, care in a nursing home 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 admittance to the  nursing  home  or  the  skilled nursing facility; and  (iii) further hospitalization would otherwise be necessary.  (D)  In  determining  the total days of coverage for nursing home care the aggregate of the number of covered days of care in  a  hospital  and the  number  of covered days of care in a nursing home, with two days of care in a nursing home equivalent to one day of care in a hospital, need  not exceed the number of covered days of hospital  care  provided  under the contract in a benefit period.  (E) The level of benefits to be provided for nursing home care must be reasonably related to the benefits provided for hospital care.  (3)  (A)  Every  insurer  delivering a group policy or issuing a group policy  for  delivery,  in  this  state,  which  provides  coverage  for in-patient  hospital  care  must  make available and if requested by the policyholder provide coverage to residents in this state for  ambulatory 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. Written notice of the availability of such coverage shall  be delivered to the policyholder prior to inception of such group policy and annually thereafter, except that this  notice  shall  not  be required  where  a  policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (B) In this paragraph:  (i)  "Ambulatory  care  in  hospital  out-patient  facilities"   means services    for   diagnostic   X-rays,   laboratory   and   pathological examinations, physical and occupational therapy and  radiation  therapy, and   services   and   medications   used   for  nonexperimental  cancer chemotherapy and cancer hormone therapy, provided that such services and medications are related to and necessary for the treatment or  diagnosis of  the  patient's illness or injury, are ordered by a physician and, in the case of physical therapy services, are to be furnished in connection with the same illness for which the patient had been hospitalized or  in connection  with  surgical  care,  but  in  no  event  need benefits for physical therapy be provided which commences more than six months  after discharge from a hospital or the date surgical care was rendered, and in no  event  need  benefits  for  physical therapy be provided after three hundred sixty-five days from the date of discharge from  a  hospital  or the date surgical care was rendered.  (ii) "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.  (C)  Such coverage shall be made available at the inception of all new policies and, with respect to  policies  issued  before  January  first, nineteen  hundred  eighty-three,  at  the  first annual anniversary date thereafter, without evidence  of  insurability  and  at  any  subsequent annual anniversary date subject to evidence of insurability.  (4)  (A)  Every  insurer  delivering a group policy or issuing a group policy for delivery, in this  state,  that  provides  reimbursement  for psychiatric or psychological services or for the diagnosis and treatment of  mental  health  conditions,  however  defined  in  such  policy,  by physicians, psychiatrists or psychologists, shall make available and  if requested  by the policyholder provide the same coverage to insureds for such services when performed  by  a  licensed  clinical  social  worker, within the lawful scope of his or her practice, who is licensed pursuant to  article  one hundred fifty-four of the education law. Written notice of  the  availability  of  such  coverage  shall  be  delivered  to  the policyholder  prior  to  inception  of  such  group  policy and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure  was  the  subject of collective bargaining affecting persons who are employed in more than one state.  (B)  The  state  board  for  social  work shall maintain a list of all licensed clinical social workers qualified for reimbursement under  this paragraph.  (C)  Such coverage shall be made available at the inception of all new policies and, with respect to  all  other  policies  at  any  subsequent annual   anniversary   date   of  the  policy  subject  to  evidence  of insurability.  (D) In addition to  the  requirements  of  subparagraph  (A)  of  this paragraph,  every  insurer  issuing  a group policy for delivery in this state  where  the  policy  provides  reimbursement   to   insureds   for psychiatric or psychological services or for the diagnosis and treatment of  mental  health  conditions,  however  defined  in  such  policy,  by physicians, psychiatrists  or  psychologists,  shall  provide  the  same coverage  to  insureds  for  such  services when performed by a licensed clinical social worker, within the lawful scope of his or her  practice, who  is  licensed  pursuant to subdivision two of section seven thousand seven hundred four of the education  law  and  in  addition  shall  have either:  (i) three or more additional years experience in psychotherapy, which for the purposes of this subparagraph shall mean the use of verbal methods in interpersonal relationships with the intent  of  assisting  a person   or   persons   to   modify  attitudes  and  behavior  that  are intellectually, socially or emotionally maladaptive, under  supervision, satisfactory to the state board for social work, in a facility, licensed or  incorporated  by  an  appropriate governmental department, providing services for diagnosis or treatment of mental  health  conditions;  (ii) three  or  more  additional  years experience in psychotherapy under the supervision, satisfactory to the state  board  for  social  work,  of  a psychiatrist,  a  licensed  and  registered  psychologist  or a licensed clinical  social  worker  qualified  for   reimbursement   pursuant   to subsection (e) of this section, or (iii) a combination of the experience specified  in  items  (i)  and  (ii) of this subparagraph totaling three years, satisfactory to the state board for social work.  (E) The state board for social work  shall  maintain  a  list  of  all licensed  clinical  social  workers  qualified  for  reimbursement under subparagraph (D) of this paragraph.  (5) (A) Every insurer delivering a group or school blanket  policy  or issuing  a  group  or school blanket policy for delivery, in this state, which provides coverage for inpatient  hospital  care  or  coverage  for physician   services  shall  provide  coverage  for  the  diagnosis  and treatment of mental health conditions and:  (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, it shall include 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 this subsection,  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, co-pays and coinsurance as may be deemed appropriate by the superintendent and shall be  consistent  with  those  imposed  on  other benefits  under  the  policy.  Provided that no copayment or coinsurance imposed for outpatient mental health services  provided  in  a  facility licensed,  certified  or  otherwise  authorized  by the office of mental health shall exceed the copayments or coinsurance imposed for a  primary care office visit under the 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.  (6) (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) The criteria for medical necessity determinations under the policy with  respect to inpatient substance use disorder benefits shall be made available by  the  insurer  to  any  insured,  prospective  insured,  or in-network provider upon request.  (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).  (7) (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 treatment  programs  and  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.  (C-1) A large group policy that provides coverage under this paragraph shall  not impose copayments or coinsurance for outpatient substance use disorder services that exceeds the copayment or coinsurance imposed  for a  primary  care  office  visit.  Provided that no greater than one such copayment may be imposed for all services provided in a single day by  a facility  licensed,  certified  or otherwise authorized by the office of alcoholism and substance abuse services to provide outpatient  substance use disorder services.  (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.  (7-a) (A) Every policy that provides medical, major medical or similar comprehensive-type large group coverage shall provide immediate coverage for  all  buprenorphine  products,  methadone  or long acting injectable  naltrexone  without  prior  authorization  for  the  detoxification   or maintenance treatment of a substance use disorder.  (B)   Coverage  provided  under  this  paragraph  may  be  subject  to copayments, coinsurance, and annual deductibles that are consistent with those imposed on other benefits within the policy.  (8) (A) Every insurer issuing a group  policy  for  delivery  in  this state that provides medical, major-medical or similar comprehensive-type coverage  shall  provide  coverage  for  the provision of preventive and primary care services.  (B) In 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 of age:  (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  group  policy  that  provides  hospital,  surgical or medical care coverage, except for  a  grandfathered  health  plan  under subparagraph  (G)  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.  (F)  The  requirements of this paragraph shall also be applicable to a blanket policy  of  hospital,  medical  or  surgical  expense  insurance covering  students  pursuant  to  subparagraph (C) of paragraph three of subsection (a) of section four thousand two hundred thirty-seven of this chapter.  (G) 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).  (9)  Every  insurer  issuing a group policy for delivery in this state which policy provides coverage for any service within the  lawful  scope of  practice of a duly licensed registered professional nurse, must make available,  and  if  requested   by   the   contract   holder,   provide reimbursement  for such service when such service is performed by a duly licensed  registered  professional   nurse   provided,   however,   that reimbursement  shall  not  be  made  for nursing services provided to an insured in a general hospital, nursing  home  or  a  facility  providing health   related   services,  as  such  terms  are  defined  in  section twenty-eight hundred one of the public health law, or in a facility,  as such  term  is  defined in subdivision six of section 1.03 of the mental hygiene law, or in a physician's office. Such coverage may be subject to annual deductibles and co-insurance as may be deemed appropriate by  the superintendent  and  are consistent with those imposed on other benefits within a given policy. Such coverage  shall  not  replace,  restrict  or eliminate  existing  coverage  provided  by the policy. Coverage for the services of a  duly  licensed  registered  professional  nurse  need  be provided  only  if  the  nature  of  the  patient's illness or condition requires nursing care which can appropriately be provided  by  a  person with  the  education and professional skill of a registered professional nurse and the  nursing  care  is  necessary  in  the  treatment  of  the patient's  illness  or  condition. Written notice of the availability of such coverage shall be delivered to the policyholder prior to  inception of  such  group  policy and annually thereafter, except that this notice shall not be  required  where  a  policy  covers  two  hundred  or  more employees  or  where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (10) (A) Every insurer issuing a group policy  for  delivery  in  this state  which  provides  coverage  for  inpatient hospital care must make available and if requested by  the  policyholder  provide  coverage  for hospice care.  Written notice of the availability of such coverage shall be delivered to the policyholder prior to inception of such group policy and  annually  thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state.  (B) For the purposes of this paragraph, hospice care  shall  mean  the care  and  treatment  of a covered person who has been certified by such person's primary attending physician as having a life expectancy of  six months or less and which is provided by a hospice organization certified pursuant  to  article  forty of the public health law or under a similar certification process  required  by  the  state  in  which  the  hospice organization is located.  (C)  Hospice  care coverage shall be at least equal to: (i) a total of two hundred ten days of coverage beginning with the first day  on  which care  is  provided,  for  inpatient  hospice  care  in a hospice or in a hospital and home care and outpatient services provided by the  hospice, including   drugs  and  medical  supplies,  and  (ii)  five  visits  for bereavement counseling services, either before or  after  the  insured's death, provided to the family of the terminally ill insured.  (D)  Such coverage shall be made available at the inception of all new policies and, with respect to policies issued before the effective  date of  this  provision,  at  the  first annual anniversary date thereafter, without  evidence  of  insurability  and  at   any   subsequent   annual anniversary date subject to evidence of insurability.  (E) Such coverage may be subject to annual deductibles and coinsurance as  may  be  deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given policy period.  (11) (A) Every insurer delivering a group or blanket policy or issuing a group or blanket policy for  delivery  in  this  state  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;  (iii)  an  annual  mammogram,  which  may  be   provided   by   breast tomosynthesis, for covered persons aged forty and older; and  (iv)  for  large  group  policies  that provide coverage for hospital, surgical or medical care, an annual mammogram for covered  persons  aged thirty-five through thirty-nine, inclusive, upon the recommendation of a physician,  subject to the insurer's determination that the mammogram is medically necessary.  (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 group or blanket  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 insurer delivering a group or blanket policy or issuing a  group  or  blanket  policy  for delivery in this state 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) Consistent with federal law  every  insurer  delivering  a  group policy  or  issuing  a  group  policy  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 policyholder, 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 the policyholder at the inception of 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.  (14) (A) Every  group  or  blanket  policy  delivered  or  issued  for delivery  in  this  state  that  provides  hospital, surgical or medical coverage  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 group or  blanket  policy  that  provides  hospital,  surgical  or medical   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) Every group or blanket policy delivered or issued for delivery in this state 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 affected 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.  (16) (A) Every group or blanket policy that  provides  medical,  major medical, or similar comprehensive type coverage that is issued, amended, renewed,  effective or delivered on or after January first, two thousand twenty, shall provide coverage for all of  the  following  services  and contraceptive methods:  (1) All FDA-approved contraceptive drugs, devices, and other products. This  includes  all  FDA-approved  over-the-counter contraceptive drugs, devices, and products as prescribed or  as  otherwise  authorized  under state or federal law. The following applies to this coverage:  (a)   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 group or blanket policy 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 paragraph;  (b)  if the covered therapeutic and pharmaceutical equivalent versions of a drug, device, or product are not available or are deemed  medically inadvisable  a  group  or  blanket  policy shall provide coverage for an alternate therapeutic  and  pharmaceutical  equivalent  version  of  the contraceptive  drug,  device,  or  product  without cost-sharing. If the attending health care provider, in his or  her  reasonable  professional judgment,  determines  that  the  use  of  a  non-covered therapeutic or pharmaceutical equivalent of a drug, device, or  product  is  warranted, the   health   care   provider's   determination  shall  be  final.  The superintendent shall  promulgate  regulations  establishing  a  process, including  timeframes,  for  an  insured,  an  insured's  designee or an insured's health care provider to  request  coverage  of  a  non-covered contraceptive drug, device, or product. Such regulations shall include a requirement that insurers use an exception form that shall meet criteria established by the superintendent;  (c)  this  coverage  shall  include  emergency  contraception  without cost-sharing when provided pursuant to a  prescription  or  order  under section  sixty-eight  hundred  thirty-one  of  the education law or when lawfully provided over the counter; and  (d) this coverage must allow for the dispensing of up to twelve months worth of a contraceptive at one time;  (2) 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;  (3) Patient education and counseling on contraception; and  (4)  Follow-up  services  related to the drugs, devices, products, and procedures covered under this paragraph, including, but not limited  to, management  of  side  effects,  counseling  for continued adherence, and device insertion and removal.  (B) A group or blanket policy subject  to  this  paragraph  shall  not impose  a  deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage provided pursuant to this paragraph.  (C) Except as otherwise authorized under this paragraph,  a  group  or blanket  policy  shall  not  impose  any  restrictions  or delays on the coverage required under this paragraph.  (D) Benefits for an enrollee under this paragraph shall  be  the  same for  an  enrollee's  covered  spouse  or  domestic  partner  and covered nonspouse dependents.  (E)  Notwithstanding  any  other  provision  of  this  subsection,   a religious  employer  may request a contract without coverage for federal food and drug administration approved  contraceptive  methods  that  are contrary  to the religious employer's religious tenets. If so requested, such contract shall  be  provided  without  coverage  for  contraceptive methods.    This  paragraph  shall  not be construed to deny an enrollee coverage of, and timely access to, contraceptive methods.  (1) For purposes of this subsection,  a  "religious  employer"  is  an entity for which each of the following is true:  (a) The inculcation of religious values is the purpose of the entity.  (b)  The  entity  primarily  employs  persons  who share the religious tenets of the entity.  (c) The entity serves primarily persons who share the religious tenets of the entity.  (d) The entity is a nonprofit organization  as  described  in  Section 6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.  (2) Every religious employer that invokes the exemption provided under this  paragraph  shall  provide  written notice to prospective enrollees prior to enrollment with the plan, listing the contraceptive health care services the employer refuses to cover for religious reasons.  (F) (1) Where a group policyholder makes an election not  to  purchase coverage   for   contraceptive  drugs  or  devices  in  accordance  with subparagraph (E) of this paragraph each certificateholder covered  under the  policy  issued  to  that group policyholder shall have the right to directly purchase the rider required by this paragraph from the  insurer which  issued  the  group policy at the prevailing small group community rate for such rider whether or not the  employee  is  part  of  a  small group.  (2)  Where  a  group  policyholder  makes  an election not to purchase coverage  for  contraceptive  drugs  or  devices  in   accordance   with subparagraph  (E)  of  this  paragraph,  the  insurer that provides such coverage  shall  provide  written  notice  to  certificateholders   upon enrollment  with the insurer of their right to directly purchase a rider for coverage for the cost of contraceptive drugs or devices. The  notice shall  also  advise the certificateholders of the additional premium for such coverage.  (G) Nothing in this paragraph shall  be  construed  as  authorizing  a group  or  blanket policy which provides coverage for prescription drugs to exclude coverage for prescription drugs prescribed for reasons  other than contraceptive purposes.  (H)   For   the   purposes   of   this   paragraph,  "over-the-counter contraceptive products"  shall  mean  those  products  provided  for  in  comprehensive  guidelines supported by the health resources and services administration as of January twenty-first, two thousand nineteen.  (17)  (A)  Every group or blanket accident and health insurance policy delivered or issued for delivery in this state which  provides  coverage for  hospital  or  surgical care coverage shall not exclude coverage for screening, diagnosis  and  treatment  of  medical  conditions  otherwise covered  by  the policy because the treatment is provided to diagnose or treat autism spectrum disorder.  (B) Every group or blanket 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  group  or  blanket  policy.  This paragraph  shall  not  be  construed  as  limiting the benefits that are otherwise available to an individual under the group or blanket  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 group or blanket  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).  (18)  Any  insurer  delivering  a group or blanket policy or issuing a group or blanket  policy  for  delivery  in  this  state  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 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; provided, however, that the provisions of this section  shall  not  supersede  the terms  of a collective bargaining agreement or apply to a policy that is the result of a collective bargaining agreement between an employer  and a recognized or certified employee organization.  (19)  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.   * (20) 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 (20)'s   * (20) Every insurer delivering a group or blanket policy or issuing a group or blanket  policy  for  delivery  in  this  state  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 (20)'s  (m) A group policy providing hospital,  surgical  or  medical  expense insurance  for other than accident only shall provide that if all or any portion of the insurance on an employee  or  member  insured  under  the policy  ceases because of termination of employment or membership in the class or classes eligible for coverage under the policy,  such  employee or  member  shall  be  entitled  without  evidence  of insurability upon application to  continue  his  hospital,  surgical  or  medical  expense insurance  for  himself  or  herself and his or her eligible dependents, subject to all of the group policy's terms and conditions applicable  to those forms of benefits and to the following conditions:  (1) Continuation shall cease on the date which the employee, member or dependant  first  becomes,  after  the date of election: (A) entitled to coverage under title XVIII of the  United  States  Social  Security  Act (Medicare)  as  amended  or  superseded;  or (B) covered as an employee, member or dependent by any other insured or uninsured arrangement  which provides  hospital,  surgical  or  medical coverage for individuals in a group which does not contain any exclusion or limitation with respect to any pre-existing condition of such employee, member or dependent, except the group insurance policy conversion option of this section  shall  not be  considered as such an arrangement under which an employee, member or dependent could become covered.  (2) (A) An employee or member who wishes continuation of coverage must request such  continuation  in  writing  within  the  sixty  day  period following  the  later  of: (i) the date of such termination; or (ii) the date the employee is sent notice by first class mail  of  the  right  of continuation by the group policyholder.  (B)  An  employee  or member who wishes continuation of coverage under subparagraph (D) of paragraph four of this subsection must  give  notice to  the  employer  or  group  policyholder  within  sixty  days  of  the determination under title II or title XVI of the  United  States  Social Security  Act  that  such employee or member was disabled at the time of termination of employment or membership or at any time during the  first sixty days of continuation of coverage.  (3)  An employee or member electing continuation must pay to the group policyholder or his employer, but not more frequently than on a  monthly basis  in  advance,  the amount of the required premium payment, but not more than one hundred two percent of the group  rate  for  the  benefits being  continued under the group policy on the due date of each payment. The employee's or member's written election  of  continuation,  together with  the first premium payment required to establish premium payment on a monthly basis in  advance,  must  be  given  to  the  policyholder  or employer  within  sixty  days  of  the  date  the employee's or member's benefits would otherwise terminate.  (4) Subject to paragraph  one  of  this  subsection,  continuation  of benefits  under  the  group policy for any person shall terminate at the first to occur of the following:  (A) The date thirty-six  months  after  the  date  the  employee's  or member's  benefits  under  the  policy  would  otherwise have terminated because of termination of employment or membership; or  (B) The end of the period for which premium payments were made, if the employee or member fails to make timely payment of  a  required  premium payment; or  (C) In the case of an eligible dependent of an employee or member, the date  thirty-six  months after the date such person's benefits under the policy would otherwise have terminated by reason of:  (i) the death of the employee or member;  (ii) the divorce or legal separation of the employee  or  member  from his or her spouse;  (iii) the employee or member becoming entitled to benefits under title XVIII of the United States Social Security Act (Medicare); or  (iv)  a  dependent  child  ceasing  to  be a dependent child under the generally applicable requirements of the policy; or  (D) The date on which the group policy is terminated or, in  the  case of an employee, the date his employer terminates participation under the group  policy.  However, if this clause applies and the coverage ceasing by reason of such termination is  replaced  by  similar  coverage  under another group policy, the following shall apply:  (i)  The  employee  or  member  shall have the right to become covered under that other group policy, for the balance of  the  period  that  he would  have  remained covered under the prior group policy in accordance with this subparagraph had a termination described in this  subparagraph not occurred, and  (ii)  The  minimum level of benefits to be provided by the other group policy shall be the applicable level of  benefits  of  the  prior  group policy  reduced  by  any benefits payable under that prior group policy, and  (iii) The prior group policy shall continue to provide benefits to the extent of its accrued liabilities and extension of benefits  as  if  the replacement had not occurred.  (5)  A  notification of the continuation privilege and the time period in which to request continuation shall be included in  each  certificate of coverage.  (6)  This  subsection  shall  not  be  applicable where a continuation benefit is available to the employee or member pursuant to Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq  or Chapter  6A  of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. However, a group policy shall offer an insured  who  has  exhausted continuation  coverage pursuant to Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et  seq.  or  Chapter  6A  of  the Public  Health  Service  Act,  42  U.S.C.  §  300  bb  -  1  et seq. the opportunity to continue coverage for up to thirty-six  months  from  the date  the  employee's  or  member's  continuation coverage began, if the employee or member  is  entitled  to  less  than  thirty-six  months  of continuation benefits under federal law.  (7)(A)  Special  enrollment period. An individual who does not have an election of continuation coverage as described  in  this  subsection  in effect  on  the effective date of the American Recovery and Reinvestment act of 2009, but who would be an assistance  eligible  individual  under Title  III  of  such  act  if  such  election  were in effect, may elect continuation coverage pursuant to this subsection. Such  election  shall be made no later than sixty days after the date the administrator of the group  health  plan  (or  other  entity  involved)  provides  the notice required by section 3001(a)(7) of the American Recovery and Reinvestment act of 2009. The administrator of the group health plan (or other entity involved) shall provide such individuals with additional notice  of  the right  to elect coverage pursuant to this paragraph within sixty days of  the date of enactment of the American Recovery and Reinvestment  act  of 2009.  (B) Continuation coverage elected pursuant to subparagraph (A) of this paragraph  shall commence with the first period of coverage beginning on or after the  date  of  the  enactment  of  the  American  Recovery  and Reinvestment  act  of  2009  and  shall  not extend beyond the period of continuation coverage that would have been required if the coverage  had instead been elected pursuant to paragraph two of this subsection.  (C)  With  respect  to  an individual who elects continuation coverage pursuant to subparagraph (A) of this paragraph, the period beginning  on the  date  of  the  qualifying event and ending on the date of the first period of coverage on or after the enactment of  the  American  Recovery and  Reinvestment  act  of  2009  shall  be  disregarded for purposes of determining the sixty-three day period  referred  to  in  section  three thousand two hundred thirty-two of this article.  (8)  For  purposes  of  this  subsection,  the  term "dependent" shall include a child as described in subsection (f) of section four  thousand two hundred thirty-five of this chapter.  (n)  In  addition  to  all  the  rights of conversion and continuation otherwise provided for herein, employees or members  insured  under  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 to have  supplementary  conversion  and  continuation  rights  in   certain circumstances as follows:  (1)  If  the  employee  or  member  insured enters upon active duty as defined in subsection (o) of this section, and  the  employer  or  group policyholder does not voluntarily maintain coverage for such employee or member insured, the employee or member insured shall be entitled to have his  or her coverage continued under the group policy in accordance with the conditions and limitations contained  in  paragraph  seven  of  this subsection  and  have issued at the end of the period of continuation an individual conversion policy subject to the terms  of  this  subsection. The  effective date for the conversion policy shall be the day following the termination of insurance under the group policy, or if  there  is  a continuation  of  coverage on the day following the end of the period of continuation.  (2) If  the  employer  or  group  policyholder  does  not  voluntarily maintain  coverage  for the employee or member insured during the period of active duty, and such employee or member insured does not  elect  the supplementary  conversion  and  continuation rights provided for herein, coverage for such employee or member insured shall be  suspended  during the period of active duty.  (3)  If  the  employee  or  member  insured  elects  the supplementary continuation right provided for herein or coverage under the group  plan is suspended, and such employee or member insured dies during the period of  active  duty, the conversion right provided by this section shall be available to the surviving spouse and children, and shall  be  available to  a  child  solely  with respect to himself or herself upon his or her attaining the limiting age of coverage  under  the  group  policy  while covered  as  a dependent thereunder. It shall also be available upon the divorce or annulment of the marriage of the employee or member  insured, to the former spouse of such employee or member insured, if such divorce or annulment occurs during the period of active duty.  (4)  If  the  employee  or  member  insured  elects  the supplementary conversion and continuation right provided for herein or coverage  under the  group  plan  is  suspended,  and such employee or member insured is either reemployed or restored to participation in the group upon  return to  civilian status, he or she shall be entitled to resume participation  in insurance offered by the group pursuant  to  this  section,  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. The  right of  resumption  provided  for  herein  shall  extend to coverage for the spouse and dependents of the employee or member insured and 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.  (5) If  the  employee  or  member  insured  elects  the  supplementary conversion and continuation coverage provided for herein:  (A)  when  such  employee  or  member  insured is either reemployed or restored to participation in the group, coverage under the supplementary rights provided for herein shall terminate on the date that coverage  is effective due to resumption of participation in the group.  (B) when such employee or member insured is not reemployed or restored to  participation in the group upon return to civilian status, he or she shall be entitled to the conversion and continuation rights provided  by subsections (e) and (m) of this section.  (i)  To  elect  an individual conversion policy pursuant to subsection (e) of this section, the employee or member insured must  apply  to  the insurer  within  thirty-one  days  of  the termination of active duty or discharge from hospitalization  incident  to  such  active  duty,  which hospitalization  continues  for a period of not more than one year. Upon commencement of coverage under the conversion right provided pursuant to subsection  (e)  of  this  section,  coverage  under  the  supplementary continuation right provided for herein shall terminate.  (ii) To elect continuation of coverage pursuant to subsections (e) and (m)  of  this  section, the employee or member insured must request such continuation of the employer within thirty-one days of  the  termination of active duty or discharge from hospitalization incident to such active duty,  which hospitalization continues for a period of not more than one year.  Upon  commencement  of  coverage  under  the  continuation  right provided  pursuant to subsection (e) of this section, coverage under the supplementary continuation right provided for  herein  shall  terminate. The  employee  or member insured shall be entitled to have issued at the end of the period of continuation an individual conversion policy.  (6) If coverage under the group plan is suspended during the period of active duty:  (A) when the employee or member insured returns  to  participation  in the  group  plan,  coverage under the group plan shall be retroactive to the date of termination of the period of active duty.  (B) when such employee or member insured is not reemployed or restored to participation in the group upon return to civilian status, he or  she shall  be entitled to the conversion and continuation rights provided by subsections (e) and (m) of this section.  (i) To elect an individual conversion policy  pursuant  to  subsection (e)  of  this  section, the employee or member insured must apply to the insurer within thirty-one days of the  termination  of  active  duty  or  discharge  from  hospitalization  incident  to  such  active duty, which hospitalization continues for a period of not more than one year.  (ii) To elect continuation of coverage pursuant to subsections (e) and (m)  of  this  section, the employee or member insured must request such continuation of the employer within thirty-one days of  the  termination of active duty or discharge from hospitalization incident to such active duty,  which hospitalization continues for a period of not more than one year. The employee or member insured shall be entitled to have issued at the end of the period of continuation an individual conversion policy.  (7) A group policy providing hospital,  surgical  or  medical  expense insurance  for other than accident only shall provide that if all or any portion of the insurance on an employee  or  member  insured  under  the policy  ceases  because  the  employee  or  member insured is ordered to active duty as defined in subsection (o) of this section, such  employee or  member  insured shall be entitled, without evidence of insurability, upon application to continue his or her hospital,  surgical  or  medical expense  insurance  for  himself  or  herself  and  his  or her eligible dependents, under the supplementary conversion and  continuation  rights provided  for  herein,  subject  to  all of the group policy's terms and conditions applicable to those forms of benefits and  to  the  following conditions:  (A)  continuation  shall  not  be available for: (i) any person who is covered, becomes covered or could be  covered  by  title  XVIII  of  the United States Social Security Act (Medicare) as amended or superseded or (ii) an employee, member or dependent who is covered, becomes covered or could  become  covered  as an employee, member or dependent by any other insured or uninsured arrangement which provides  hospital,  surgical  or medical  coverage  for  individuals in a group, except that the coverage available to active duty members of the  uniformed  services  and  their family  members  shall not be considered a group under the terms of this subsection, and except that the group insurance policy conversion option of this section shall not be considered as  such  an  arrangement  under which an employee, member or dependent could become covered.  (B)  an employee or member insured who wishes continuation of coverage pursuant to this subsection must request such  continuation  in  writing within sixty days of being ordered to active duty.  (C)  an  employee  or member insured electing continuation pursuant to this subsection must pay  to  the  group  policyholder  or  his  or  her employer,  but  not  more frequently than on a monthly basis in advance, the amount of the required premium payment, but not more than the  group rate  for the benefits being continued under the group policy on the due date of each payment.  (8) The supplementary conversion and continuation rights provided  for herein shall apply to:  (A)  policies  not  covered  by  Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of  the Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;  (B)  policies  covered by Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the  Public Health  Service  Act, 42 U.S.C. section 300bb-1 et seq, when active duty for reservists and the refusal of an employer  to  voluntarily  maintain coverage  for  such period of active duty is not considered a qualifying event.  (o) To be entitled to the right defined  in  subsection  (n)  of  this section  a  person  must be a member of a reserve 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.  (p)(1) Except as provided in this section, if an insurer  delivers  or issues  for  delivery  in  this  state  a  group or blanket policy which provides hospital, surgical or medical expense coverage for  other  than accident only, the insurer must renew or continue in force such coverage at the option of the policyholder.  (2) An insurer may nonrenew or discontinue coverage under such a group or blanket policy based only on one or more of the following:  (A)  The  policyholder  or  a  participating  entity has failed to pay premiums or contributions in accordance with the terms of the policy  or the insurer has not received timely premium payments.  (B) The policyholder or a participating entity has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.  (C)  The  policyholder  has  failed  to  comply  with  a material plan provision relating  to  employer  contribution  or  group  participation rules,  as permitted under section four thousand two hundred thirty-five of this chapter.  (D) The insurer is ceasing to offer group or  blanket  policies  in  a market in accordance with paragraph three or seven of this subsection.  (E) The policyholder ceases to meet the requirements for a group under section  four  thousand  two  hundred  thirty-five  of this chapter or a participating employer, labor union, association or other entity  ceases membership  or participation in the group to which the policy is issued. Coverage terminated pursuant to this paragraph shall be  done  uniformly without  regard  to  any  health  status-related  factor relating to any covered individual.  (F) In the case of an insurer that offers a group or blanket policy in a market through a network plan, there is  no  longer  any  enrollee  in connection  with  such  plan who lives, resides, or works in the service area of the insurer (or in the area for which the insurer is  authorized to do business).  (G)  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.  (3)(A) In any case in which an insurer decides to discontinue offering a particular class of group or blanket policy of hospital,  surgical  or medical  expense  insurance  offered in the small or large group market, the policy  of  such  class  may  be  discontinued  by  the  insurer  in accordance with this chapter in such market only if:  (i)  the insurer provides written notice to each policyholder provided coverage of this class in such market (and to all employees  and  member insureds  covered  under  such coverage) of such discontinuance at least ninety days prior to the date of discontinuance  of  such  coverage.  In addition   to   any   other  information  required  of  notices  by  the superintendent, this  written  notice  shall  conspicuously  include  an explanation,  in  plain  language,  of  the  policyholder's  and covered  employee's or member insured's rights under this subparagraph and (B) of this paragraph, including:  (I) a statement that if the superintendent determines that the covered employee,   member  insured,  or  a  dependent  has  a  serious  medical condition, and the covered employee, member insured or dependent  within the  previous  twelve months utilized a benefit under the policy related to the serious medical condition that is not covered by the  replacement coverage  offered to the policyholder as a result of the discontinuance, then  the  superintendent  shall  require  the  insurer  to  offer   the policyholder  replacement  coverage  that includes a benefit that is the same as or substantially similar to the benefit set forth in the  policy that the insurer discontinued; and  (II)  an  explanation as to how to contact the superintendent, and the date  by  which  the  superintendent  shall   be   contacted,   if   the policyholder,  covered  employee  or  member  insured  believes that the covered employee, member insured or a dependent has  a  serious  medical condition,  and the covered employee, member insured or dependent within the previous twelve months utilized a benefit  related  to  the  serious medical  condition  that  may not be covered by the replacement coverage offered to the policyholder as a result of the discontinuance;  (ii) the insurer offers to each policyholder provided coverage of this class in such market, the option to purchase all (or, in the case of the large group market, any) other hospital, surgical  and  medical  expense coverage  currently  being  offered  by  the  insurer to a group in such market;  (iii) in exercising the option to discontinue coverage of  this  class and  in  offering  the  option  of  coverage  under  item  (ii)  of this subparagraph, the insurer acts uniformly without regard  to  the  claims experience  of  those  policyholders or any health status-related factor relating to any particular covered employee, member insured or dependent or particular new employee, member insured or dependent who  may  become eligible  for  such  coverage,  and the insurer is not discontinuing the coverage of this class with the intent or as a pretext to  discontinuing the coverage of any such employee, member insured or dependent; and  (iv)  at least ninety days prior to the date of discontinuance of such coverage, the insurer provides written notice to the  superintendent  of such discontinuance, including the reason for the discontinuance, and an officer  or director of the insurer certifies to the superintendent that the insurer has  complied  with  items  (i),  (ii)  and  (iii)  of  this paragraph.  If  such  notice does not include the date or dates that the insurer mailed or delivered the notice  to  all  policyholders,  covered employers   and   member   insureds,   the   insurer  shall  notify  the superintendent of such date within seven days of the completion  of  the mailing or delivery.  (B) If the superintendent determines that the insurer has not complied with  item  (iii)  of  subparagraph  (A)  of  this  paragraph,  then the superintendent may prohibit the insurer from discontinuing the class  of policies  and require the insurer to promptly notify every policyholder, covered  employee  and  member  insured  that   the   insurer   is   not discontinuing  the  policies.  If the superintendent determines that the insurer wrongfully discontinued the class of policies pursuant  to  item (iii)  of  subparagraph  (A), then the superintendent shall require that the  insurer  take  remedial  action,  including   offering   to   group policyholders  the  option of reinstating the discontinued policy forms. If the superintendent determines that the insurer discontinued the class of policies  without  compliance  with  items  (i),  (ii),  or  (iv)  of subparagraph  (A),  and an employee, member insured or dependent covered under the discontinued policy would have been entitled to  relief  under  this  paragraph,  then  the  superintendent may require that the insurer offer replacement coverage to an affected policyholder  consistent  with item (ii) of subparagraph (C) of this paragraph.  (C) (i) If, within forty-five days after the insurer mails or delivers the   written   notice   of  discontinuance  required  by  item  (i)  of subparagraph (A) of this paragraph, the superintendent is notified by  a policyholder  or  covered  employee  or  member  insured  that a covered employee, member insured or dependent has a  serious  medical  condition and  that  a benefit utilized by the covered employee, member insured or dependent within the previous  twelve  months  related  to  the  serious medical condition may not be covered by the replacement coverage offered to  the  policyholder  as  a  result  of  the  discontinuance,  then the superintendent shall, within twenty days of the  notification,  ask  the insurer  to  confirm  that  the  covered  employee,  member  insured  or dependent utilize a benefit within the previous twelve months  to  treat the  medical  condition  that  the  covered  employee, member insured or dependent asserts is a serious medical condition, and that  the  benefit is  not  covered  by  the  replacement  coverage. The superintendent may request such additional information as the superintendent  may  require. The   insurer   shall   provide   all   requested   information  to  the superintendent within five days of receipt of the request.  (ii) If, within twenty days of the  superintendent's  receipt  of  all additional  information  requested  from the insurer, the superintendent determines that (I) the covered employee, member  insured  or  dependent has  a  serious  medical condition; and (II) the benefit utilized by the covered employee, member insured or dependent within the previous twelve months related to the serious medical condition is not  covered  by  the replacement  coverage  offered  to  the  policyholder as a result of the discontinuance, then the superintendent shall  require  the  insurer  to offer  to  the policyholder replacement coverage that includes a benefit that is the same as or substantially similar to the benefit set forth in the policy that the insurer discontinued. If the replacement coverage is not  available,  at  the  time  that  the  policy  would  otherwise   be discontinued,  then  the insurer shall keep the existing policy in force for the affected policyholder until the replacement  coverage  with  the substantially similar benefit is available.  (D) The remedies as provided in this paragraph shall be in addition to and not in lieu of any other authority or power of the superintendent to impose monetary or other penalties for violations of this paragraph.  (E) In any case in which an insurer elects to discontinue offering all hospital,  surgical  and  medical  expense  coverage  in the small group market or the large group market, or both markets, in this state, health insurance coverage may be discontinued by the insurer only if:  (i) the insurer provides written notice to the superintendent  and  to each  policyholder  (and all employees and member insureds covered under such coverage) of such discontinuance at least one hundred  eighty  days prior to the date of the discontinuance of such coverage;  (ii)  all  hospital,  surgical  and medical expense coverage issued or delivered for issuance in this state in  such  market  (or  markets)  is discontinued  and  coverage  under  such  policies  in  such  market (or markets) is not renewed; and  (iii) in addition to the notice to the superintendent referred  to  in item   (i)   of   this  subparagraph,  the  insurer  shall  provide  the superintendent with a written plan to minimize potential  disruption  in the marketplace occasioned by the insurer's withdrawal from the market.  (F)  In  the  case  of  a discontinuance under subparagraph (E of this paragraph in a market, the insurer may not provide for the  issuance  of any  group  or  blanket  policy of hospital, surgical or medical expense  insurance in that market in this  state  during  the  five  year  period beginning on the date of the discontinuance of the last health insurance policy not so renewed.  (4)  At the time of coverage renewal, an insurer may modify the health insurance coverage for a group or blanket policy offered to a  large  or small group policyholder so long as such modification is consistent with this  chapter  and  effective  on  a uniform basis among all small group policyholders with that policy form.  (5) 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  either with the insurer or another entity which has contracted with the insurer.  (6) For purposes  of  this  subsection,  the  term  "dependent"  shall include  a child as described in subsection (f) of section four thousand two hundred thirty-five of this chapter.  (7) Notwithstanding paragraph three of this subsection, an insurer may discontinue offering a particular class of group or  blanket  policy  of hospital,  surgical or medical expense insurance offered in the small or large group market, and instead offer  a  group  or  blanket  policy  of hospital,  surgical  or medical expense insurance that complies with the requirements of section 2707 of the public  health  service  act,  §  42 U.S.C.  300gg-6  that  become  applicable  to  such policy as of January first, two thousand fourteen, provided that the insurer:  (A) discontinues the existing class of policy in  such  market  as  of either  December  thirty-first,  two  thousand  thirteen  or  the policy renewal date occurring in two thousand fourteen in accordance with  this chapter;  (B)  provides written notice to each policyholder provided coverage of the class in the market  (and  to  all  employees  and  member  insureds covered  under such coverage) of the discontinuance at least ninety days prior to the date of discontinuance of such coverage. The written notice shall be in a form satisfactory to the superintendent;  (C) offers to each policyholder provided coverage of the class in  the market,  the  option to purchase all (or, in the case of the large group market, any) other hospital, surgical and medical expense coverage  that complies  with  the  requirements  of  section 2707 of the public health service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage as of January first, two thousand fourteen, currently being  offered  by the insurer to a group in that market;  (D)  in exercising the option to discontinue coverage of the class and in offering the option  of  coverage  under  subparagraph  (C)  of  this paragraph,  acts  uniformly  without  regard to the claims experience of those policyholders or any health status-related factor relating to  any particular  covered employee, member insured or dependent, or particular new employee, member insured, or dependent who may become  eligible  for such  coverage,  and does not discontinue the coverage of the class with the intent or as a pretext to discontinuing the  coverage  of  any  such employee, member insured, or dependent; and  (E)  at  least  one  hundred  twenty  days  prior  to  the date of the discontinuance  of  such  coverage,  provides  written  notice  to   the superintendent  of  the  discontinuance,  including  certification by an officer  or  director  of  the  insurer  that   the   reason   for   the discontinuance  is  to  replace  the  coverage  with  new  coverage that complies with the requirements of section  2707  of  the  public  health service  act,  §  42 U.S.C. 300gg-6 that become effective January first,  two thousand fourteen. The written notice shall  be  in  such  form  and contain such information the superintendent requires.  (q)(1)  No  insurer delivering or issuing for delivery in this state a group or blanket policy which provides  hospital,  surgical  or  medical expense  coverage  shall  establish  rules  for  eligibility  (including continued eligibility) of any individual or dependent of the  individual to  enroll  under  the  policy  based  on  any  of  the following health status-related factors:  (A) Health status.  (B) Medical condition (including both physical and mental illnesses).  (C) Claims experience.  (D) Receipt of health care.  (E) Medical history.  (F) Genetic information.  (G) Evidence of insurability (including conditions arising out of acts of domestic violence).  (H) Disability.  (2) For purposes of  paragraph  one  of  this  subsection,  rules  for eligibility  include  rules  defining any applicable waiting periods for such enrollment.  (3) No insurer may, on the basis of any health  status-related  factor in  relation  to  the  insured  or dependent of the insured, require any insured (as a condition of enrollment or continued enrollment under  the policy)  to  pay  a  premium  or contribution which is greater than such premium for a similarly situated insured enrolled in the plan.  (4) Nothing in this subsection shall require an  insurer  to  issue  a group  or blanket policy to a group comprised of fifty-one or more lives exclusive of spouses and dependents.  (5) Where an eligible insured  or  dependent  of  an  insured  rejects initial  enrollment in a group or blanket policy that provides hospital, surgical or medical  expense  insurance,  an  insurer  shall  permit  an insured  or  dependent  of  an  insured to enroll for coverage under the terms of the policy if each of the following conditions is met:  (A) The insured or dependent was covered under another plan or  policy at the time coverage was initially offered.  (B)(i)  Coverage  under  the  other  plan  or  policy  was provided in accordance with continuation required by federal or state  law  and  was exhausted; or  (ii)  Coverage  under  the  other  plan  or  policy  was  subsequently terminated as a result of loss of eligibility for one  or  more  of  the following reasons:  (I) termination of employment;  (II) termination of the other plan or policy;  (III) death of the spouse;  (IV) legal separation, divorce, or annulment;  (V) reduction in the number of hours of employment; or  (iii) Policyholder contributions toward the payment of premium for the other plan or contract were terminated.  (C) Coverage must be applied for within thirty days of termination for one of the reasons set forth in subparagraph (B) of this paragraph.  (6)  With respect to group or blanket policies delivered or issued for delivery in this state covering  between  two  and  fifty  employees  or members,  the provisions of this subsection shall in no way diminish the rights of such groups pursuant to section  three  thousand  two  hundred thirty-one of this article.  (7)  For  purposes  of  this  subsection,  the  term "dependent" shall include a child as described in subsection (f) of section four  thousand two hundred thirty-five of this chapter.  (r)  (1)  As used in this subsection, "child" means an unmarried child through age twenty-nine of an employee or member insured under  a  group policy of hospital, medical or surgical expense insurance, regardless of financial  dependence,  who  is  not insured by or eligible for coverage under any 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 and who is  not  covered  under title XVIII of the United States Social Security Act (Medicare).  (2) In addition to the conversion privilege afforded by subsection (e) of  this  section  and the continuation privilege afforded by subsection (m) of this section, every group policy delivered or issued for delivery in this state  that  provides  hospital,  medical  or  surgical  expense insurance  coverage  for other than specific diseases or accidents only, and which provides coverage of a child that terminates  at  a  specified age,  shall,  upon  application of the employee, member or child, as set forth in subparagraph (B) of this paragraph,  provide  coverage  to  the child  after  that  specified  age  and  through age twenty-nine without evidence of insurability, subject to all of the terms and conditions  of the group policy and the following:  (A)  An  employer shall not be required to pay all or part of the cost of coverage for a child provided pursuant to this subsection;  (B) An employee, member or child who wishes to elect  continuation  of coverage  pursuant  to this subsection shall request the continuation in writing:  (i) within sixty days following  the  date  coverage  would  otherwise terminate  due  to  reaching  the  specified  age set forth in the group policy;  (ii) within sixty days after meeting the requirements for child status set forth in paragraph one of this  subsection  when  coverage  for  the child previously terminated; or  (iii) during an annual thirty-day open enrollment period, as described in the policy;  (C) An employee, member or child electing continuation as described in this subsection shall pay to the group policyholder or employer, but not more  frequently  than  on a monthly basis in advance, the amount of the required premium payment on the due date of each  payment.  The  written election  of  continuation,  together  with  the  first  premium payment required to establish premium payment on a  monthly  basis  in  advance, shall  be  given  to  the group policyholder or employer within the time periods set forth in subparagraph (B) of  this  paragraph.  Any  premium received  within  the  thirty-day  period  after  the  due date shall be considered timely;  (D) For any child electing coverage within sixty days of the date  the child would otherwise lose coverage due to reaching a specified age, the effective  date  of the continuation coverage shall be the date coverage would have otherwise  terminated.  For  any  child  electing  to  resume coverage  during an annual open enrollment period, the effective date of the continuation coverage shall be prospective no later than thirty days after the election and payment of first premium;  (E) Coverage for a child pursuant to this subsection shall consist  of coverage  that  is identical to the coverage provided to the employee or member parent. If coverage is modified under the policy for any group of similarly situated employees or members, then the coverage shall also be modified in the same manner for any child;  (F) Coverage shall terminate on the first to occur of the following:  (i) the date the child no longer meets the requirements  of  paragraph one of this subsection;  (ii)  the  end  of the period for which premium payments were made, if there is a failure to make payment of a required premium payment  within the period of grace described in subparagraph (C) of this paragraph; or  (iii)  the  date  on  which  the  group  policy  is terminated and not replaced by coverage under another group policy; and  (G) The insurer shall provide written notification of the continuation privilege described in this subsection and the time period in  which  to request continuation to the employee or member:  (i) in each certificate of coverage; and  (ii)  at least sixty days prior to termination at the specified age as provided in the policy.  (3)(A) Insurers shall submit such reports as may be requested  by  the superintendent  to  evaluate  the  effectiveness of coverage pursuant to this subsection including, but  not  limited  to,  quarterly  enrollment reports.  (B)  The  superintendent  may  promulgate  regulations  to  ensure the orderly  implementation  and  operation  of  the  continuation  coverage provided   pursuant   to   this   subsection,   including  premium  rate adjustments.  (s) An insurer subject  to  the  provisions  of  this  article  or  an insurance  producer subject to this chapter shall not permit the renewal of a small group policy that  provides  hospital,  surgical  or  medical expense  coverage  that  renews  on or after January first, two thousand fourteen, but before July first, two thousand fourteen, so as  to  renew the  same  policy prior to the policy's annual renewal date for the sole purpose of evading the requirements  of  the  affordable  care  act  and regulations  promulgated  thereunder  with  respect  to  such policy. An isolated, inadvertent renewal date change which was  not  made  for  the sole  purpose  of  evading  the  requirements of the affordable care act shall not be deemed a violation of this subsection.  (t) (1) Any insurer that delivers or issues for delivery in this state hospital, surgical or medical expense group policies in the small  group or large group market shall offer to any employer in this state all such policies  in  the  applicable  market,  and  shall  accept  at all times throughout the year any employer that applies for any of those policies.  (2) The requirements of paragraph one of this subsection  shall  apply with  respect  to  an employer that applies for coverage either directly from the insurer or through an association or trust to which the insurer has issued coverage and in which the employer participates.