2023 New York Laws › ISC - Insurance › Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations › 4306-H - Essential Health Benefits Package and Limit on Cost-Sharing.

§ 4306-h. Essential health benefits package and limit on cost-sharing.
(a)  (1) For purposes of this article, "essential health benefits" shall
mean the following categories of benefits:
(A) ambulatory patient services;
(B) emergency services;
(C) hospitalization;
(D) maternity and newborn care;
(E) mental health  and  substance  use  disorder  services,  including
behavioral health treatment;
(F) prescription drugs;
(G) rehabilitative and habilitative services and devices;
(H) laboratory services;
(I)  preventive  and wellness services and chronic disease management;
and
(J) pediatric services, including oral and vision care.
(2) A corporation shall  not  be  required  to  provide  coverage  for
pediatric oral services as an essential health benefit if:
(A)  for  coverage  offered  through  the exchange established by this
state, the exchange has determined sufficient coverage of the  pediatric
oral  benefit is available through stand-alone dental plans certified by
the exchange; or
(B) for coverage offered outside the exchange, the corporation obtains
reasonable written assurance that the individual or group has obtained a
stand-alone dental plan that has been approved by the superintendent  as
meeting exchange certification standards.
(b)  (1)  Every  individual  and  small  group  contract that provides
hospital,  surgical,  or  medical  expense  coverage  and   is   not   a
grandfathered   health  plan  shall  provide  coverage  that  meets  the
actuarial requirements of one of the following levels of coverage:
(A) Bronze Level. A plan in the bronze level shall provide a level  of
coverage  that  is  designed  to  provide  benefits that are actuarially
equivalent to sixty percent of the full actuarial value of the  benefits
provided under the plan;
(B)  Silver Level. A plan in the silver level shall provide a level of
coverage that is designed  to  provide  benefits  that  are  actuarially
equivalent  to  seventy  percent  of  the  full  actuarial  value of the
benefits provided under the plan;
(C) Gold Level. A plan in the gold level  shall  provide  a  level  of
coverage  that  is  designed  to  provide  benefits that are actuarially
equivalent to eighty percent of the full actuarial value of the benefits
provided under the plan; or
(D) Platinum Level. A plan in the platinum level shall provide a level
of coverage that is designed to provide benefits  that  are  actuarially
equivalent to ninety percent of the full actuarial value of the benefits
provided under the plan.
(2)  The  superintendent  may provide for a variation in the actuarial
values used in determining the level of coverage of a  plan  to  account
for the differences in actuarial estimates.
(3) Every student accident and health insurance contract shall provide
coverage  that  meets at least sixty percent of the full actuarial value
of the benefits provided under the contract. The contract's schedule  of
benefits  shall  include the level as described in paragraph one of this
subsection nearest to, but below the actual actuarial value.
(c)  Every  individual  or  group  contract  that  provides  hospital,
surgical,  or medical expense coverage and is not a grandfathered health
plan, and every student accident and  health  insurance  contract  shall
limit  the  insured's cost-sharing for in-network services in a contract
year to not more than the maximum out-of-pocket amount determined by the

superintendent for all contracts subject to this  section.  Such  amount
shall  not  exceed any annual out-of-pocket limit on cost-sharing set by
the United States secretary of health and human services, if available.
(d)   The  superintendent  may  require  the  use  of  model  language
describing the coverage requirements for any form that is subject to the
approval of the superintendent pursuant to section four  thousand  three
hundred eight of this article.
(e) For purposes of this section:
(1)  "actuarial  value"  means  the  percentage  of the total expected
payments  by  the  corporation  for  benefits  provided  to  a  standard
population,  without  regard  to  the population to whom the corporation
actually provides benefits;
(2) "cost-sharing" means annual deductibles, coinsurance,  copayments,
or similar charges, for covered services;
(3) "essential health benefits package" means coverage that:
(A) provides for essential health benefits;
(B)   limits   cost-sharing  for  such  coverage  in  accordance  with
subsection (c) of this section; and
(C) provides one of the levels of coverage described in subsection (b)
of this section;
(4)  "grandfathered  health  plan"  means  coverage  provided   by   a
corporation  in  which an individual was enrolled on March twenty-third,
two thousand ten for as long as  the  coverage  maintains  grandfathered
status in accordance with section 1251(e) of the Affordable Care Act, 42
U.S.C. § 18011(e);
(5)  "small  group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and
(6) "student accident and health insurance" shall have the meaning set
forth in subsection (a) of section three thousand two hundred  forty  of
this chapter.