2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3217-I - Essential Health Benefits Package and Limit on Cost-Sharing.

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