2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3216 - Individual Accident and Health Insurance Policy Provisions.

§  3216.  Individual  accident and health insurance policy provisions.
(a) In this section the term:
(1) "Policy of accident and health insurance" includes any  individual
policy  or contract covering the kind or kinds of insurance described in
paragraph three of subsection (a) of section one  thousand  one  hundred
thirteen of this chapter.
(2) "Indemnity" means benefits promised.
(3) "Family"  may  include  the  policyholder's  spouse,  or dependent
children, or any other person dependent upon the policyholder.
(4) "Dependent children"  (A)  shall  include  any  children  under  a
specified age which shall not exceed age nineteen except:
(i) Any unmarried dependent child, regardless of age, who is incapable
of   self-sustaining   employment   by  reason  of  mental  illness,  or
developmental disability as  defined  in  the  mental  hygiene  law,  or
physical  handicap and who became so incapable prior to the age at which
dependent coverage would  otherwise  terminate,  shall  be  included  in
coverage subject to any pre-existing conditions limitation applicable to
other dependents; or
(ii)  Any  unmarried  student at an accredited institution of learning
may be considered a dependent child until attaining age twenty-three for
a policy other than hospital, medical, surgical,  or  prescription  drug
expense insurance; or
(iii)  Any  married or unmarried child shall be considered a dependent
child  until  attaining  age  twenty-six  without  regard  to  financial
dependence,   residency   with  the  policyholder,  student  status,  or
employment, for a policy of hospital, medical, surgical, or prescription
drug expense insurance.
(B) may include, at the option of the  insurer,  any  unmarried  child
until  attaining  age  twenty-five  for  a  policy  other than hospital,
medical, surgical, or prescription drug expense insurance.
(C) In addition to the requirements of subparagraphs (A)  and  (B)  of
this  paragraph, every insurer issuing a policy of hospital, medical, or
surgical expense  insurance  pursuant  to  this  section  that  provides
coverage for dependent children must make available and, if requested by
the policyholder, extend coverage under the policy to an unmarried child
through  age  twenty-nine, without regard to financial dependence who is
not insured by or eligible for coverage under an employer health benefit
plan as an employee or member, whether insured or self-insured, and  who
lives,  works  or  resides  in New York state or the service area of the
insurer. Such coverage shall be made available at the inception  of  all
new  policies. Written notice of the availability of such coverage shall
be delivered to the policyholder thirty days prior to the  inception  of
such policy.
(b)   No   policy   of   accident   and  health  insurance,  including
non-cancellable disability insurance, except as provided  in  subsection
(h)  hereof,  shall  be  delivered  or issued for delivery in this state
until the rate manual showing rates, rules and classifications of  risks
for  use  in connection with such accident and health insurance policies
or with  riders  or  endorsements  thereon,  has  been  filed  with  the
superintendent.
(c)  No  policy of accident and health insurance shall be delivered or
issued for delivery to any person in this state unless:
(1) The entire money and other considerations therefor  are  expressed
therein.
(2)  The  time  at  which the insurance takes effect and terminates is
expressed therein.
(3) It purports to insure only one person, except that  a  policy  may
insure,  originally  or by subsequent amendment, members of a family, as

defined herein, upon the application of an adult member  of  the  family
who shall be deemed the policyholder.
(4)  (A)  Coverage of an unmarried dependent child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability,  as  defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment  of  the  age  at  which
dependent   coverage  would  otherwise  terminate  and  who  is  chiefly
dependent upon such policyholder for support and maintenance, shall  not
terminate while the policy remains in force and the dependent remains in
such  condition,  if the policyholder has within thirty-one days of such
dependent's attainment of the  limiting  age  submitted  proof  of  such
dependent's incapacity as described herein.
(B)  Coverage  of  a  dependent  spouse  or  named insured which would
terminate upon such spouse or named insured attaining the age prescribed
in subchapter XVIII of the federal Social Security  Act,  42  U.S.C.  §§
1395  et  seq.  ("medicare"),  as  the  age of first eligibility for the
benefits provided by such law shall not so terminate, if such  dependent
spouse is not then eligible for all of such benefits, for as long as the
policy  remains in force and such dependent spouse remains ineligible to
receive  any  of  such  "medicare"  benefits,  provided  proof  of  such
ineligibility  is submitted to the insurer within thirty-one days of the
date notice of termination of coverage be sent by first  class  mail  by
the insurer to the last known address of the policyholder.
(C)  Any  family  coverage  shall  provide  that  coverage  of newborn
infants,  including  newly  born  infants  adopted  by  the  insured  or
subscriber  if  such insured or subscriber takes physical custody of the
infant upon such infant's release from the hospital and files a petition
pursuant to section one hundred fifteen-c of the domestic relations  law
within  thirty  days  of  birth;  and provided further that no notice of
revocation to the adoption  has  been  filed  pursuant  to  section  one
hundred  fifteen-b  of  the  domestic  relations  law and consent to the
adoption has not been revoked, shall be effective  from  the  moment  of
birth  for injury or sickness including the necessary care and treatment
of  medically  diagnosed  congenital  defects  and  birth  abnormalities
including premature birth, except that in cases of adoption, coverage of
the initial hospital stay shall not be required where a birth parent has
insurance  coverage  available  for  the  infant's  care. In the case of
individual coverage the insurer must also permit the person to whom  the
policy  is  issued  to  elect  such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or contribution is required to make coverage  effective  for  a  newborn
infant, the coverage may provide that such notice and/or payment be made
within  no  less  than  thirty days of the day of birth to make coverage
effective from the moment of birth. This election shall not be  required
in the case of student insurance.
(5)  (A)  Any  family  policy  providing  hospital or surgical expense
insurance (but not including such insurance  against  accidental  injury
only)  shall  provide  that,  in the event such insurance on any person,
other than the policyholder, is terminated  because  the  person  is  no
longer  within  the  definition of the family as set forth in the policy
but before such person has  attained  the  limiting  age,  if  any,  for
coverage  of  adults  specified  in  the  policy,  such  person shall be
entitled to have issued to that person by the insurer, without  evidence
of  insurability,  upon  application  therefor  and payment of the first
premium, within sixty days after such insurance shall  have  terminated,
an  individual  conversion  policy  that  contains  the essential health
benefits package described in  paragraph  three  of  subsection  (f)  of
section  three  thousand  two  hundred  seventeen-i of this article. The

insurer shall offer one policy at each level of coverage as  defined  in
subsection (b) of section three thousand two hundred seventeen-i of this
article.  The  individual  may  choose  any  such  policy offered by the
insurer.  Provided,  however,  the  superintendent may, after giving due
consideration to the public interest,  approve  a  request  made  by  an
insurer for the insurer to satisfy the requirements of this subparagraph
through  the  offering of policies that comply with this subparagraph by
another insurer, corporation or health maintenance  organization  within
the  insurer's  holding company system, as defined in article fifteen of
this chapter.  The conversion privilege afforded herein  shall  also  be
available  upon  the  divorce  or  annulment  of  the  marriage  of  the
policyholder to the former spouse of such policyholder.
(B) Written notice of entitlement to  a  conversion  policy  shall  be
given  by  the insurer to the policyholder at least fifteen and not more
than sixty days prior to the termination of coverage due to the  initial
limiting  age  of  the  covered  dependent. Such notice shall include an
explanation of the rights of the dependent with respect to the dependent
being enrolled in an accredited institution of learning or  his  or  her
incapacity  for  self-sustaining employment by reason of mental illness,
developmental disability  as  defined  in  the  mental  hygiene  law  or
physical handicap.
(C)  Such  individual  conversion  policy  shall  be  subject  to  the
following terms and conditions:
(i) The premium shall be that applicable to the  form  and  amount  of
insurance therefor.
(ii)  The  benefits  provided under such policy shall become effective
upon the date that such person was no longer eligible under  the  family
policy.
(iii)  No insurer shall be required to issue a conversion policy if it
appears that the person applying for such policy shall have at that time
in force another insurance policy or hospital service or medical expense
indemnity contract providing similar benefits or is  covered  by  or  is
eligible  for coverage by a group insurance policy or contract providing
similar benefits or shall be covered by similar benefits required by any
statute or provided by any welfare plan or program, which together  with
the  conversion  policy would result in over insurance or duplication of
benefits according to standards on file with the superintendent relating
to individual policies.
(6) The style, arrangement and overall appearance of the  policy  give
no undue prominence to any portion of the text, and unless every printed
portion  of  the  text of the policy and of any endorsements or attached
papers is plainly printed in light-faced type of a style in general use,
the size of which shall be uniform and not less than  ten-point  with  a
lower-case   unspaced   alphabet   length  not  less  than  one  hundred
twenty-point (the "text" shall include all  printed  matter  except  the
name  and address of the insurer, name or title of the policy, the brief
description, if any, and captions and subcaptions).
(7) The exceptions and reductions of indemnity are set  forth  in  the
policy  and,  except those which are set forth in subsection (d) of this
section, are printed, at the insurer's option, either included with  the
benefit  provision  to which they apply, or under an appropriate caption
such as "EXCEPTIONS", or "EXCEPTIONS AND REDUCTIONS", provided  that  if
an  exception  or  reduction  specifically  applies only to a particular
benefit of the policy, a statement of such exception or reduction  shall
be included with the benefit provision to which it applies.
(8)  Each  such  form,  including  riders  and  endorsements, shall be
identified by a form number in the lower left-hand corner of  the  first
page thereof.
(9)  It  contains  no  provision purporting to make any portion of the
charter, rules, constitution, or by-laws of the insurer a  part  of  the
policy unless such portion is set forth in full in the policy, except in
the  case of the incorporation of, or reference to, a statement of rates
or   classification  of  risks,  or  short-rate  table  filed  with  the
superintendent.
(10) There is prominently printed on the first page thereof  or  there
is  attached  thereto  a  notice  to  the effect that during a specified
period of time, which shall not be less than  ten  days  nor  more  than
twenty  days  from the date the policy is delivered to the policyholder,
it may be surrendered to the insurer together with a written request for
cancellation of the policy and in such event the insurer will refund any
premium paid therefor  including  any  policy  fees  or  other  charges,
provided, however, that this paragraph shall not apply to single premium
nonrenewable  policies  insuring  against  accidents  only or accidental
bodily injuries only; provided, however, that a contract or  certificate
sold  by  mail  order  and  a contract or certificate providing medicare
supplemental insurance  or  long-term  care  insurance  must  contain  a
provision  permitting  the  contract  or certificate holder a thirty day
period for such surrender.
(11) The age limit or date or period, if any, after which the coverage
provided by the policy will not be effective or the age limit,  date  or
period  after which the policy may not be renewed is stated in a renewal
provision set forth on the first page of the policy  or  as  a  separate
provision bearing an appropriate caption on the first page of the policy
or in a brief description in not less than fourteen-point bold face type
set  forth  on  the  first  page of the policy. Nothing herein contained
shall limit or restrict the right of the insurer to continue the  policy
after the age or period so stated.
(12)  Any  policy,  other  than  one  issued  in  fulfillment  of  the
continuing care responsibilities of an operator  of  a  continuing  care
retirement  community in accordance with article forty-six of the public
health  law,  made  available  because  of  residence  in  a  particular
facility,  housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS POLICY DOES NOT MEET THE REQUIREMENTS OF  A  CONTINUING
CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY
A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."
(13)  Any  persons  covered  by  the  policy who are also members of a
reserve component of the armed forces of the  United  States,  including
the  National  Guard,  shall  be entitled, upon written request, to have
their coverage suspended during a period of  active  duty  as  described
herein.    The  policy  shall  provide  that the insurer will refund any
unearned premiums for the period of such suspension. Persons covered  by
the  policy  shall  be  entitled to resumption of coverage, upon written
application and payment of the required premium within sixty days  after
the  date  of  termination  of  the  period  of  active  duty,  with  no
limitations or conditions imposed as a result of such period  of  active
duty  except  as set forth in subparagraphs (A) and (B) herein. Coverage
shall be retroactive to the date of termination of the period of  active
duty.  Such right of resumption provided for herein shall be in addition
to other existing rights granted pursuant to state and federal laws  and
regulations  and  shall not be deemed to qualify or limit such rights in
any way. No exclusion or waiting period may  be  imposed  in  connection
with  coverage of a health or physical condition of a person entitled to
such right of resumption, or a health or physical condition of any other
person who is covered by the policy unless:
(A) the condition arose during the  period  of  active  duty  and  the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(B)  a  waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall  the  sum  of  the
waiting  periods  imposed  prior  to  and  subsequent  to  the period of
suspension exceed the length of the waiting period originally imposed.
(14) To be entitled to the right defined in paragraph thirteen of this
subsection a person must be a member of a component of the armed  forces
of the United States, including the National Guard, who either:
(A)  voluntarily  or involuntarily enters upon active duty (other than
for the purpose of determining his or her  physical  fitness  and  other
than for training), or
(B)  has  his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units  of  the
ready reserve or members of a reserve component to active duty, provided
that  such  additional  active  duty  is  at  the  request  and  for the
convenience of the federal government, and
(C) serves no more than four years of active duty.
* (15) Space shall be provided on any enrollment, renewal  or  initial
online  portal  process  setup forms required of an insured or applicant
for insurance, except forms issued  by  the  NY  State  of  Health,  the
official   Health   Plan  Marketplace,  other  than  those  specifically
referenced in subparagraph (iv) of paragraph (a) of subdivision five  of
section four thousand three hundred ten and paragraph (v) of subdivision
one  of section two hundred six of the public health law, required of an
insured or applicant for insurance so  that  the  insured  or  applicant
shall  register  or decline registration in the donate life registry for
organ, eye and tissue donations under this section of the enrollment  or
renewal  form  and that the following is stated on the form in clear and
conspicuous type:
"You must fill out the following section: Would you like to  be  added
to  the  Donate  Life  Registry?  Check  box  for  'yes'  or  'skip this
question'."
* NB Effective June 23, 2024
(d) Each policy of accident and health insurance delivered  or  issued
for  delivery  to  any person in this state shall contain the provisions
specified herein  in  the  words  in  which  the  same  appear  in  this
subsection,  except  that the insurer may, at its option, substitute for
one or more of such provisions  corresponding  provisions  of  different
wording  approved  by the superintendent which are not less favorable in
any respect to the insured or the beneficiary. Each provision  contained
in  the policy shall be preceded by the applicable caption herein or, at
the insurer's option, by such appropriate captions or subcaptions as the
superintendent may approve.
(1) Each policy shall, except with respect to designation  by  numbers
or letters as used below, contain the following provisions:
(A)  ENTIRE CONTRACT; CHANGES: This policy, including the endorsements
and the attached papers, if any,  constitutes  the  entire  contract  of
insurance.  No change in this policy shall be valid until approved by an
executive officer of the insurer and unless such  approval  be  endorsed
hereon  or  attached  hereto. No agent or broker has authority to change
this policy or to waive any of its provisions.
(B) TIME LIMIT ON CERTAIN DEFENSES:
(i) After two  years  from  the  date  of  issue  of  this  policy  no
misstatements, except fraudulent misstatements, made by the applicant in
the  application  for such policy shall be used to void the policy or to

deny a claim for loss incurred or disability (as defined in the  policy)
commencing after the expiration of such two year period.
The foregoing policy provision shall not be so construed as to affect
any  legal  requirement  for  avoidance of a policy or denial of a claim
during such initial two year period, nor to  limit  the  application  of
subparagraphs (A) through (E), inclusive, of this paragraph in the event
of misstatement with respect to age or occupation or other insurance.)A policy which the insured has the right to continue in force subject
to  its  terms by the timely payment of premium until at least age fifty
or, in the case of a policy issued after age forty-four,  for  at  least
five  years from its date of issue, may contain in lieu of the foregoing
the following provision (from which the clause  in  parentheses  may  be
omitted at the insurer's option) under the caption "INCONTESTABLE":
After  this  policy has been in force for a period of two years during
the lifetime of the insured  (excluding  any  period  during  which  the
insured is disabled), it shall become incontestable as to the statements
contained in the application.)
(ii)  No  claim  for  loss  incurred  or disability (as defined in the
policy) commencing after two years from the date of issue of this policy
shall be reduced or denied on the ground  that  a  disease  or  physical
condition  not  excluded  from  coverage by name or specific description
effective on the date of loss had existed prior to the effective date of
coverage of this policy.
(C) GRACE PERIOD: A grace period of ........................ (insert a
number not less than "7" for weekly premium policies, "10"  for  monthly
premium  policies  and "31" for all other policies) days will be granted
for the payment of each premium falling due  after  the  first  premium,
during which grace period the policy shall continue in force.
A  policy  in  which the insurer reserves the right to refuse renewal
shall have, at the beginning  of  the  above  provision,  the  following
clause:
"Unless  not  less  than  thirty  days  prior  to the renewal date the
insurer has delivered to the insured or has sent by first class mail  to
his  last  address as shown by the records of the insurer written notice
of its intention not to renew this policy beyond the  period  for  which
the premium has been accepted,"
Furthermore, such a policy, except an accident only policy, shall also
provide  in  substance,  in  a  provision  thereof, or in an endorsement
thereon or in a rider attached thereto,  that  the  insurer  may  refuse
renewal  of  the  policy  only  as  of the renewal date occurring on, or
nearest its first anniversary, or as of an anniversary of  such  renewal
date,  or  at the option of the insurer as of the renewal date occurring
on or nearest the anniversary of its date of last reinstatement.)
(D) REINSTATEMENT: If any renewal premium be not paid within the  time
granted  the insured for payment, a subsequent acceptance of the premium
by the insurer or by any agent or broker duly authorized by the  insurer
to  accept  such  premium,  without requiring in connection therewith an
application for reinstatement, shall  reinstate  the  policy;  provided,
however,  that  if  the  insurer  or  such  agent  or broker requires an
application for reinstatement and issues a conditional receipt  for  the
premium  tendered,  the  policy will be reinstated upon approval of such
application  by  the  insurer  or,  lacking  such  approval,  upon   the
forty-fifth  day  following  the date of such conditional receipt unless
the insurer has previously  notified  the  insured  in  writing  of  its
disapproval  of such application. The reinstated policy shall cover only
loss resulting from such accidental injury as may be sustained after the
date of reinstatement and loss due to such sickness as  may  begin  more
than  ten  days  after  such date. In all other respects the insured and

insurer shall have the same rights thereunder  as  they  had  under  the
policy immediately before the due date of the defaulted premium, subject
to  any provisions endorsed hereon or attached hereto in connection with
the   reinstatement.   Any   premium   accepted  in  connection  with  a
reinstatement shall be applied to a period for  which  premium  has  not
been  previously  paid, but not to any period more than sixty days prior
to the date of reinstatement.
The last sentence of the above provision  may  be  omitted  from  any
policy  which  the insured has the right to continue in force subject to
its terms by the timely payment of premiums until at least age fifty or,
in the case of a policy issued after age forty-four, for at  least  five
years from its date of issue.)
(E)  NOTICE  OF  CLAIM:  Written  notice of claim must be given to the
insurer within twenty days after the occurrence or commencement  of  any
loss  covered  by  the  policy,  or  as soon thereafter as is reasonably
possible. Notice given by or on behalf of the insured or the beneficiary
to the insurer at -------------- (insert the location of such office  as
the  insurer  may designate for the purpose), or to any authorized agent
of the insurer or to any authorized broker, with information  sufficient
to  identify  the  insured, shall be deemed notice to the insurer. (In a
policy providing a loss-of-time benefit which  may  be  payable  for  at
least  two  years,  an  insurer  may  at its option insert the following
between the first and second sentences of the above  provision:  Subject
to  the  qualifications  set forth below, if the insured suffers loss of
time on account of disability for which indemnity may be payable for  at
least  two  years,  he  shall,  at  least once in every six months after
having given notice of claim, give to the insurer notice of  continuance
of  said disability, except in the event of legal incapacity. The period
of six months following any filing  of  proof  by  the  insured  or  any
payment  by  the  insurer  on  account  of  such  claim or any denial of
liability in whole or in part  by  the  insurer  shall  be  excluded  in
applying  this  provision.  Delay in the giving of such notice shall not
impair the insured's right to any indemnity which would  otherwise  have
accrued during the period of six months preceding the date on which such
notice is actually given.)
(F)  CLAIM FORMS: The insurer, upon receipt of a notice of claim, will
furnish to the claimant such forms as are usually furnished  by  it  for
filing  proofs  of  loss. If such forms are not furnished within fifteen
days after the giving of such notice the claimant  shall  be  deemed  to
have  complied  with the requirements of this policy as to proof of loss
upon submitting, within the time fixed in the policy for  filing  proofs
of loss, written proof covering the occurrence, the character and extent
of the loss for which claim is made.
(G)  PROOFS  OF  LOSS:  Written proof of loss must be furnished to the
insurer at its said office in case of claim  for  loss  for  which  this
policy  provides  any  periodic  payment contingent upon continuing loss
within ninety days after the termination of the  period  for  which  the
insurer  is  liable  and  in case of claim for any other loss within one
hundred twenty days after the date of such loss. Failure to furnish such
proof within the time required shall not invalidate nor reduce any claim
if it was not reasonably  possible  to  give  proof  within  such  time,
provided  such  proof is furnished as soon as reasonably possible and in
no event, except in the absence of legal capacity, later than  one  year
from the time proof is otherwise required.
(H)  TIME  OF PAYMENT OF CLAIMS: Indemnities payable under this policy
for any loss other than loss for which this policy provides any periodic
payment will be paid immediately upon receipt of due  written  proof  of
such loss. Subject to due written proof of loss, all accrued indemnities

for  loss  for  which  this  policy  provides  periodic  payment will be
paid ------------ (insert period for payment  which  must  not  be  less
frequently  than  monthly)  and  any  balance  remaining unpaid upon the
termination  of  liability  will be paid immediately upon receipt of due
written proof.
(I) PAYMENT OF CLAIMS: Any indemnity for loss of life will be  payable
in  accordance  with  the  beneficiary  designation  and  the provisions
respecting such payment which may be prescribed herein and effective  at
the  time  of  payment.  If  no  such  designation  or provision is then
effective, such indemnity shall be payable to the estate of the insured.
Any other accrued indemnities unpaid at the insured's death may, at  the
option  of  the  insurer,  be paid either to such beneficiary or to such
estate. All other indemnities will be payable  to  the  insured.
The
following  provisions,  or  either  of  them,  may  be included with the
foregoing provision at the option of the insurer: If  any  indemnity  of
this  policy  shall  be  payable  to the estate of the insured, or to an
insured or beneficiary who is a minor or otherwise not competent to give
a valid release, the insurer may pay such indemnity, up to an amount not
exceeding $-------------- (insert an amount which shall not  exceed  one
thousand dollars), to any relative by blood or connection by marriage of
the  insured or beneficiary who is deemed by the insurer to be equitably
entitled thereto. Any payment made by the insurer in good faith pursuant
to this provision shall fully discharge the insurer  to  the  extent  of
such payment.
Subject  to any written direction of the insured in the application or
otherwise all or a portion of any indemnities provided by this policy on
account of hospital, nursing, medical, or surgical services may, at  the
insurer's  option  and  unless the insured requests otherwise in writing
not later than the time of filing proofs of such loss, be paid  directly
to  the  hospital  or  person  rendering  such  services;  but it is not
required that the service  be  rendered  by  a  particular  hospital  or
person.)
(J)  PHYSICAL EXAMINATIONS AND AUTOPSY: The insurer at its own expense
shall have the right and  opportunity  to  examine  the  person  of  the
insured  when  and  as  often  as  it  may reasonably require during the
pendency of a claim hereunder and to make an autopsy in  case  of  death
where it is not forbidden by law.
(K)  LEGAL  ACTIONS: No action at law or in equity shall be brought to
recover on this policy prior to  the  expiration  of  sixty  days  after
written  proof  of  loss  has  been  furnished  in  accordance  with the
requirements of this policy. No such action shall be brought  after  the
expiration  of  three  years  after  the  time  written proof of loss is
required to be furnished.
(L) CHANGE OF BENEFICIARY: Unless the  insured  makes  an  irrevocable
designation  of  beneficiary,  the  right  to  change  of beneficiary is
reserved  to  the  insured  and  the  consent  of  the  beneficiary   or
beneficiaries  shall not be requisite to surrender or assignment of this
policy or to any change of beneficiary or beneficiaries, or to any other
changes in this policy.
(The first  clause  of  this  provision,  relating  to  the  irrevocable
designation of beneficiary, may be omitted at the insurer's option.)
(M)  "CONVERSION  PRIVILEGE"  (under  this  caption) a provision which
shall set forth in  substance  the  conversion  privileges  and  related
provisions  required of certain policies by paragraph five of subsection
(c) of this section.
(2) Other provisions. No such policy delivered or issued for  delivery
to  any  person  in  this  state shall contain provisions respecting the
matters set forth below unless such provisions are  in  the  words  (not

including  the designation by number or letter) in which the same appear
in this paragraph except that the insurer may, at  its  option,  use  in
lieu  of  any  such  provision  a  corresponding  provision of different
wording  approved  by  the superintendent which is not less favorable in
any respect to the  insured  or  the  beneficiary.  Any  such  provision
contained   in   the  policy  shall  be  preceded  individually  by  the
appropriate caption appearing herein or, at the option of  the  insurer,
by  such  appropriate individual or group captions or subcaptions as the
superintendent may approve.
(A) CHANGE OF OCCUPATION:  If  the  insured  be  injured  or  contract
sickness  after  having  changed his occupation to one classified by the
insurer as more hazardous than that stated in this policy or while doing
for compensation anything pertaining to an occupation so classified, the
insurer will pay only such portion of the indemnities provided  in  this
policy  as the premium paid would have purchased at the rates and within
the limits fixed by the insurer for such more hazardous  occupation.  If
the  insured  changes his occupation to one classified by the insurer as
less hazardous than that  stated  in  this  policy,  the  insurer,  upon
receipt  of  proof of such change of occupation, will reduce the premium
rate accordingly, and will return the excess pro-rata  unearned  premium
from  the  date  of  change of occupation or from the policy anniversary
date immediately preceding receipt of such proof, whichever is the  more
recent.  In  applying this provision, the classification of occupational
risk and the premium rates shall be such as have been last filed by  the
insurer  prior  to  the  occurrence of the loss for which the insurer is
liable or prior to date of proof of change in occupation with the  state
official  having supervision of insurance in the state where the insured
resided at the time this policy was issued; but if such filing  was  not
required,  then  the classification of occupational risk and the premium
rates shall be those last made effective by the insurer  in  such  state
prior  to  the  occurrence  of the loss or prior to the date of proof of
change in occupation.
(B) MISSTATEMENT OF AGE: If the insured's age has been misstated,  all
amounts  payable  under  this  policy  shall be such as the premium paid
would have purchased at the correct age.
(C) OTHER INSURANCE IN THIS INSURER: If an  accident  or  sickness  or
accident  and health policy or policies previously issued by the insurer
to the insured be in force concurrently herewith,
making  the  aggregate  indemnity  for  ------------(insert  type   of
coverage  or coverages) in excess of $-------------(insert maximum limit
of indemnity or indemnities) the excess insurance shall be void and  all
premiums paid for such excess shall be returned to the insured or to his
estate,
or, in lieu thereof:
Insurance effective at any one time on the insured under a like policy
or policies in this insurer is limited to the one such policy elected by
the  insured, his beneficiary or his estate, as the case may be, and the
insurer will return all premiums paid for all other such policies.
(D) INSURANCE WITH OTHER INSURERS: If there be other  valid  coverage,
not  with  this  insurer,  providing  benefits  for  the  same loss on a
provision of service basis or on an expense incurred basis and of  which
this  insurer  has not been given written notice prior to the occurrence
or commencement of loss, the only liability under any  expense  incurred
coverage  of this policy shall be for such proportion of the loss as the
amount which would otherwise have been payable hereunder plus the  total
of  the  like  amounts under all such other valid coverages for the same
loss of which this insurer had notice bears to the  total  like  amounts
under  all  valid  coverages  for  such loss, and for the return of such

portion of the premiums paid as shall exceed the  pro-rata  portion  for
the  amount  so  determined.  For the purpose of applying this provision
when other coverage is on  a  provision  of  service  basis,  the  "like
amount"  of  such  other coverage shall be taken as the amount which the
services rendered would have cost in the absence of such coverage.
If the foregoing policy provision is included in a policy which  also
contains the next following policy provision there shall be added to the
caption  of  the  foregoing  provision  the phrase "--- EXPENSE INCURRED
BENEFITS". The insurer may, at its option, include in this  provision  a
definition  of  "other  valid  coverage",  approved  as  to  form by the
superintendent, which definition shall be limited in subject  matter  to
coverage  provided  by  organizations subject to regulation by insurance
law or by insurance authorities of this or any other state of the United
States or any province of Canada, and by  hospital  or  medical  service
organizations,  and  to any other coverage the inclusion of which may be
approved by the superintendent. In the absence of such  definition  such
term  shall  not  include  group  insurance, automobile medical payments
insurance,  or  coverage  provided  by  hospital  or   medical   service
organizations  or by union welfare plans or employer or employee benefit
organizations. For the purpose of applying the foregoing provision  with
respect  to any insured, any amount of benefit provided for such insured
pursuant to any  compulsory  benefit  statute  (including  any  workers'
compensation  or  employer's  liability  statute)  whether provided by a
governmental agency or otherwise shall in all  cases  be  deemed  to  be
"other  valid coverage" of which the insurer has had notice. In applying
the foregoing policy provision no third party liability  coverage  shall
be included as "other valid coverage".)
(E)  INSURANCE  WITH OTHER INSURERS: If there be other valid coverage,
not with this insurer, providing benefits for the  same  loss  on  other
than  an  expense  incurred basis and of which this insurer has not been
given written notice prior to the occurrence or  commencement  of  loss,
the only liability for such benefits under this policy shall be for such
proportion of the indemnities otherwise provided hereunder for such loss
as  the  like indemnities of which the insurer had notice (including the
indemnities under this policy) bear to the  total  amount  of  all  like
indemnities  for  such  loss,  and for the return of such portion of the
premium paid as shall exceed the pro-rata portion  for  the  indemnities
thus determined.
If  the foregoing policy provision is included in a policy which also
contains the next preceding policy provision there shall be added to the
caption of the foregoing provision the phrase "--- OTHER BENEFITS".  The
insurer  may,  at  its option, include in this provision a definition of
"other valid coverage", approved as to form by the superintendent, which
definition shall be limited in subject matter to  coverage  provided  by
organizations  subject  to  regulation  by insurance law or by insurance
authorities of this or any other state  of  the  United  States  or  any
province of Canada, and to any other coverage the inclusion of which may
be  approved  by  the  superintendent. In the absence of such definition
such term shall not include group insurance,  or  benefits  provided  by
union  welfare  plans  or by employer or employee benefit organizations.
For the purpose of applying the foregoing policy provision with  respect
to any insured, any amount of benefit provided for such insured pursuant
to  any  compulsory benefit statute (including any workers' compensation
or employer's liability statute)  whether  provided  by  a  governmental
agency  or  otherwise  shall  in  all cases be deemed to be "other valid
coverage" of which the insurer has had notice. In applying the foregoing
policy provision no third party liability coverage shall be included  as
"other valid coverage".)
(F)  RELATION OF EARNINGS TO INSURANCE: If the total monthly amount of
loss of time benefits promised for the same loss under all valid loss of
time coverage upon the insured, whether payable on a weekly  or  monthly
basis,  shall  exceed  the  monthly  earnings of the insured at the time
disability  commenced  or his average monthly earnings for the period of
two years immediately preceding a disability for which  claim  is  made,
whichever  is  the  greater,  the  insurer  will be liable for only such
proportionate amount of such benefits under this policy as the amount of
such monthly earnings or such average monthly earnings  of  the  insured
bears  to  the  total amount of monthly benefits for the same loss under
all such coverage upon the insured at the time such disability commences
and for the return of such part of the premiums  paid  during  such  two
years  as  shall  exceed  the  pro-rata  amount  of the premiums for the
benefits actually paid hereunder; but this shall not operate  to  reduce
the  total  monthly  amount  of benefits payable under all such coverage
upon the insured below the sum of two hundred dollars or the sum of  the
monthly  benefits  specified in such coverages, whichever is the lesser,
nor shall it operate to reduce benefits other  than  those  payable  for
loss of time.
The foregoing policy provision may be inserted only in a policy which
the  insured  has the right to continue in force subject to its terms by
the timely payment of premiums until at least age fifty or, in the  case
of  a  policy  issued after age forty-four, for at least five years from
its date of issue. The insurer may,  at  its  option,  include  in  this
provision  a definition of "valid loss of time coverage", approved as to
form by the superintendent, which definition shall be limited in subject
matter to coverage provided by governmental agencies or by organizations
subject to regulation by the insurance law or by  insurance  authorities
of  this  or  any  other  state  of the United States or any province of
Canada, or to any other coverage the inclusion of which may be  approved
by  the  superintendent  or  any  combination  of such coverages. In the
absence of such definition such term  shall  not  include  any  coverage
provided  for  such  insured  pursuant to any compulsory benefit statute
(including any workers' compensation or employer's  liability  statute),
or  benefits  provided by union welfare plans or by employer or employee
benefit organizations.)
(G) UNPAID PREMIUM: Upon the payment of a claim under this policy, any
premium then due and unpaid or covered by any note or written order  may
be deducted therefrom.
(H)  CANCELLATION:  Within  the  first  ninety  days after the date of
issue, the insurer may cancel this policy by written notice delivered to
the insured, or sent by first class mail to his last address as shown by
the records of the  insurer,  stating  when,  not  less  than  ten  days
thereafter,  such  cancellation  shall  be  effective.  In  the event of
cancellation, the insurer will return  promptly  the  pro-rata  unearned
portion  of any premium paid. Cancellation shall be without prejudice to
any claim originating prior to the effective date of cancellation.
Nothing in this subsection shall be construed to prohibit an  insurer
from  granting  to  the insured the right to cancel a policy at any time
and to receive in such event a refund of the  unearned  portion  of  any
premium  paid,  computed  by  the use of the short-rate table last filed
with the state official having supervision of  insurance  in  the  state
where the insured resided when the policy was issued).
(I)  CONFORMITY  WITH  STATE  STATUTES:  Any  provision of this policy
which, on its effective date, is in conflict with the  statutes  of  the
state  in  which  the  insured resides on such date is hereby amended to
conform to the minimum requirements of such statutes.
(J) ILLEGAL OCCUPATION: The insurer shall not be liable for  any  loss
to which a contributing cause was the insured's commission of or attempt
to  commit  a  felony or to which a contributing cause was the insured's
being engaged in an illegal occupation.
(K) INTOXICANTS AND NARCOTICS: The insurer shall not be liable for any
loss  sustained  or  contracted  in  consequence  of the insured's being
intoxicated or under the influence of any narcotic  unless  administered
on the advice of a physician.
(3)  If  any  provision  of  this  subsection  is  in whole or in part
inapplicable  to  or  inconsistent  with  the  coverage  provided  by  a
particular  form  of  policy  the  insurer,  with  the  approval  of the
superintendent, shall omit from such policy any  inapplicable  provision
or  part  of a provision, and shall modify any inconsistent provision or
part of the provision in  such  manner  as  to  make  the  provision  as
contained  in  the  policy  consistent with the coverage provided by the
policy.
(4) The provisions which are the subject of paragraphs one and two  of
this  subsection, or any corresponding provisions which are used in lieu
thereof in accordance with such paragraphs,  shall  be  printed  in  the
consecutive order of the provisions in such paragraphs or, at the option
of  the  insurer, any such provision may appear as a unit in any part of
the policy, with other provisions to which it may be logically  related,
provided  the  resulting  policy  shall  not  be  in  whole  or  in part
unintelligible, uncertain, ambiguous, abstruse, or likely to  mislead  a
person to whom the policy is offered, delivered or issued.
(5)  The  word  "insured",  as  used  in  this  section,  shall not be
construed as preventing a person other than the insured  with  a  proper
insurable  interest  from  making  application  for  and owning a policy
covering the insured or from being entitled under such a policy  to  any
indemnities, benefits and rights provided therein.
(6)  The superintendent may make such reasonable rules and regulations
concerning the procedure  for  the  filing  or  submission  of  policies
subject  to  this  section  as are necessary, proper or advisable to the
administration of this section. This provision  shall  not  abridge  any
other authority granted the superintendent by law.
(e)  The  acknowledgment by any insurer of the receipt of notice given
under any policy covered by this section, or the furnishing of forms for
filing proofs of  loss,  or  the  acceptance  of  such  proofs,  or  the
investigation  of any claim thereunder, shall not operate as a waiver of
any of the rights of the insurer in defense of any claim  arising  under
such policy.
(f)  If  any  such policy contains a provision establishing, as an age
limit or otherwise, a date after which  the  coverage  provided  by  the
policy will not be effective, and if such date falls within a period for
which  premium  is  accepted  by the insurer or if the insurer accepts a
premium after such date,  the  coverage  provided  by  the  policy  will
continue  in force subject to any right of cancellation until the end of
the period for which premium has been accepted. In the event the age  of
the  insured  has been misstated and if, according to the correct age of
the insured, the coverage provided by the policy would not  have  become
effective,  or would have ceased prior to the acceptance of such premium
or premiums, then the liability of the insurer shall be limited  to  the
refund, upon request, of all premiums paid for the period not covered by
the policy.
(g)(1) No insurer shall refuse to renew a policy of hospital, surgical
or  medical  expense  insurance,  an individual converted policy, or any
other policy in  which  one-third  or  more  of  the  total  premium  is
allocable  to  hospital,  surgical  or  medical expense benefits, or any

combination thereof (but  not  including  insurance  against  accidental
injury only), except for one or more of the following reasons:
(A) nonpayment of premiums,
(B)  fraud  in applying for the policy or in applying for any benefits
under the policy or intentional misrepresentation of material fact under
the terms of the coverage,
(C) discontinuance of a class of policies in accordance with paragraph
two of this subsection, except that no insurer or organization certified
pursuant to article forty-four of the public health law shall refuse  to
renew  the  policies  of  insureds holding contracts which provide major
medical or similar comprehensive type coverage in effect prior  to  June
first,  two thousand one who are ineligible to purchase policies offered
pursuant to section four  thousand  three  hundred  twenty-one  or  four
thousand  three hundred twenty-two of this chapter due to the provisions
of section 42 USC 1395ss in effect on January first, two  thousand  one,
and who are eligible for Medicare benefits by reason of disability.
(i)  Coverage shall be reinstated only for such insureds terminated on
or after January first, two thousand one  and  such  coverage  shall  be
reinstated on a prospective basis only, irrespective of any pre-existing
conditions.
(ii)  In  the  event  any  such  insured  becomes eligible to purchase
policies  offered  pursuant  to  section  four  thousand  three  hundred
twenty-one  or  four  thousand three hundred twenty-two of this chapter,
then such insured may be discontinued upon not  less  than  five  months
prior written notice. In the event any such insured becomes eligible for
Medicare  by  reason  of age, then such insured may be terminated by not
less than thirty days notice with prior written notice.
(iii) Within sixty days of this item taking  effect,  the  insurer  or
organization  shall  notify the insured of the prospective reinstatement
of coverage under this section. Within thirty days of  receipt  of  such
notice,  an  insured  shall notify the insurer or organization of his or
her election for prospective coverage,
(D) discontinuance of  all  hospital,  surgical  and  medical  expense
coverage  in  the  individual  market  in  this state in accordance with
paragraph three of this subsection,
(E) in the case of an insurer that offers coverage in  the  individual
market  through  a  network  plan,  termination  of an individual who no
longer resides, lives or works in the service area (or in  an  area  for
which  the  insurer  is  authorized  to  do  business)  but only if such
coverage is terminated under this subparagraph uniformly without  regard
to any health status-related factor of covered individuals, and
(F) for such other reasons as are acceptable to the superintendent and
authorized by the Health Insurance Portability and Accountability Act of
1996,  Public  Law  104-191,  and  any  later  amendments  or  successor
provisions, or by any federal regulations or rules  that  implement  the
provisions of the Act.
In  no event shall any insurer refuse to renew any such policy because
of the physical or mental condition or the health of any person  covered
thereunder. Furthermore, no insurer shall require as a condition for the
renewal  of  any  such policy any rider, endorsement or other attachment
which shall  limit  the  nature  or  extent  of  the  benefits  provided
thereunder.  The  superintendent  may require every insurer to file with
him such  documents,  statistics  or  other  information  regarding  the
refusal  to  renew permitted by this subsection as he may deem necessary
for the proper administration of this subsection.
(2) In any case in which an insurer decides to discontinue offering  a
class   of  hospital,  surgical  or  medical  expense  policies  in  the

individual health insurance market, coverage of the  class  of  policies
may be discontinued by the insurer only if:
(A)  the  insurer  gives  at least ninety days prior written notice of
such discontinuance to the superintendent;
(B) the insurer provides written notice of such discontinuance to each
covered  individual  at  least  ninety  days  prior  to  the   date   of
discontinuance of such coverage;
(C)  the  insurer  offers  to  each  covered  individual the option to
purchase all other individual hospital,  surgical  and  medical  expense
coverage currently being offered by the insurer in the individual health
insurance market; and
(D)  in  exercising  the  option to discontinue coverage of a class of
policies and in offering the option of coverage under  subparagraph  (C)
of  this  paragraph, the insurer acts uniformly without regard to claims
experience or to any health status-related factor of insured individuals
or individuals who may become eligible for such coverage.
(E) The superintendent may, after  giving  due  consideration  to  the
public interest, approve a request made by an insurer for the insurer to
satisfy  the  requirements of subparagraph (C) of this paragraph through
the offering of policies  at  each  level  of  coverage  as  defined  in
subsection (b) of section three thousand two hundred seventeen-i of this
article that contains the essential health benefits package described in
paragraph  three of subsection (e) of section three thousand two hundred
seventeen-i of this article by another insurer,  corporation  or  health
maintenance  organization  within  the  insurer's  same  holding company
system, as defined in article fifteen of this chapter.
(3) In any case in which an insurer elects to discontinue offering all
hospital, surgical and medical expense coverage in the individual market
in this state, health insurance coverage  may  be  discontinued  by  the
insurer only if:
(A)  the  insurer gives at least one hundred eighty days prior written
notice of such discontinuance to the superintendent;
(B) the insurer provides written notice of such discontinuance to each
covered individual at least one hundred eighty days prior to the date of
termination of such coverage;
(C) all hospital, surgical and  medical  expense  coverage  issued  or
delivered  for  issuance  in  this  state  in  the  individual market is
discontinued and coverage under such health insurance coverage  in  such
market is not renewed; and
(D)  in addition to the notice referred to in subparagraph (A) of this
paragraph, the insurer must provide the superintendent  with  a  written
plan  to  minimize potential disruption in the marketplace occasioned by
its withdrawal from the individual market.
(4) In the case of a discontinuance  under  paragraph  three  of  this
subsection,  the  insurer may not provide for the issuance of any policy
of hospital, surgical or medical expense  insurance  in  the  individual
market  in  this state during the five year period beginning on the date
of the discontinuance of the  last  health  insurance  coverage  not  so
renewed.
(5)  At the time of coverage renewal, an insurer may modify the health
insurance coverage for a policy  form  offered  to  individuals  in  the
individual  market  so long as such modification is consistent with this
chapter and effective on a uniform basis among all individuals with that
policy form.
(6) For purposes of this subsection the term "network plan" shall mean
a health insurance policy under which  the  financing  and  delivery  of
health  care  (including  items  and services paid for as such care) are
provided, in whole or in part, through a defined set of providers  under

contract  with  the  insurer or another entity which has contracted with
the insurer.
(h) This section shall not apply to or affect:
(1)  Any  contract  of  non-cancellable  disability insurance which is
governed by or excepted from section three thousand two hundred  fifteen
of this article.
(2) Any policy or contract of reinsurance.
(3)  Any  policy  of  group  or blanket insurance which is governed by
section three thousand two hundred twenty-one  of  this  article  except
that  the provisions of subsection (b) hereof and paragraphs one through
ten of subsection (i) hereof and the provisions of subsection (j) hereof
shall be applicable to a policy  of  group  insurance  authorized  under
subparagraph  (J)  of  paragraph  one  of subsection (c) of section four
thousand two hundred thirty-five of this chapter.
(4) Any policy providing disability benefits pursuant to article  nine
of the workers' compensation law.
(5)  Any  policy of a co-operative life and accident insurance company
except as was provided in section two hundred thirty-seven of the former
insurance law.
(6) Life insurance,  endowment  or  annuity  contracts,  or  contracts
supplemental  thereto  which  contain  only  such provisions relating to
accident and health insurance as provide additional benefits in case  of
death  or  dismemberment  or loss of sight by accident, or as operate to
safeguard such contracts against lapse, or to give a  special  surrender
value  or special benefit or an annuity in the event that the insured or
annuitant shall become totally and permanently disabled, as  defined  by
the contract or supplemental contract.
(i)  Every  person  insured  under  a  policy  of  accident and health
insurance delivered or issued  for  delivery  in  this  state  shall  be
entitled to the reimbursements and coverages specified below.
(1)  If a policy provides for reimbursement for any optometric service
which is within the lawful scope of practice of a licensed  optometrist,
the  insured shall be entitled to reimbursement for such service whether
it is performed by a physician  or  licensed  optometrist.  Unless  such
policy  shall  otherwise  provide  there  shall  be no reimbursement for
ophthalmic materials, lenses, spectacles, eyeglasses,  or  appurtenances
thereto.
(2) If a policy provides for reimbursement for any podiatrical service
within  the  lawful  scope  of  practice  of  a licensed podiatrist, the
insured shall be entitled to reimbursement for such service  whether  it
is performed by a physician or licensed podiatrist.
(3)  If  a  policy  provides  for reimbursement for any dental service
within the lawful scope of practice of a licensed dentist,  the  insured
shall  be  entitled  to  reimbursement  for  such  service whether it is
performed by a physician or a licensed dentist.
(4)  If  a  policy  provides  for  reimbursement  for  psychiatric  or
psychological  services  or for diagnosis and treatment of mental health
conditions however defined in the policy, the insured shall be  entitled
to  reimbursement  for  such  services,  diagnosis  or treatment whether
performed by a  physician,  psychiatrist,  a  certified  and  registered
psychologist,  or  a  nurse  practitioner when the services rendered are
within the lawful scope of their practice.
(5) Every policy providing for reimbursement for laboratory  tests  or
reimbursement   for   diagnostic   X-ray   services  shall  provide  for
reimbursement at the same percentage of reimbursement whether such tests
or services are provided to the insured as  an  admitted  patient  in  a
health care facility or as an out-patient.
(6)  Every policy which provides coverage for in-patient hospital care
shall provide coverage for home care to residents in  this  state.  Such
home  care  coverage  shall  be  included  at  the  inception of all new
policies and, with respect to all other  policies,  at  any  anniversary
date of the policy subject to evidence of insurability.
(A)  Home care means the care and treatment of a covered person who is
under the care of a physician but only if hospitalization or confinement
in a nursing facility as defined in  subchapter  XVIII  of  the  federal
Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
required  if  home care was not provided, and the plan covering the home
health service is established and approved in writing by such physician.
Home care shall be provided by an agency possessing a valid  certificate
of  approval  or  license  issued  pursuant to article thirty-six of the
public health law and shall consist of one or more of the following:
(i) Part-time or intermittent  home  nursing  care  by  or  under  the
supervision of a registered professional nurse (R.N.).
(ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
(iii) Physical, occupational or speech therapy if provided by the home
health service or agency.
(iv)   Medical   supplies,  drugs  and  medications  prescribed  by  a
physician, and laboratory services by or on behalf of a  certified  home
health  agency  or licensed home care services agency to the extent such
items would have been covered under the contract if the  covered  person
had  been  hospitalized  or  confined  in  a skilled nursing facility as
defined in title subchapter XVIII of the federal Social Security Act, 42
U.S.C.  §§ 1395 et seq.
(B) Coverage may be subject to an annual deductible of not  more  than
fifty  dollars  for  each  person  covered  under  the policy and may be
subject to a coinsurance provision which provides for  coverage  of  not
less  than  seventy-five  percent  of  the  reasonable  charges for such
services. For the purpose of determining  the  benefits  for  home  care
available  to  a  covered  person, each visit by a member of a home care
team shall be considered as  one  home  care  visit;  the  contract  may
contain  a  limitation  on  the number of home care visits, but not less
than forty such visits in any calendar year or in any continuous  period
of  twelve months for each person covered under the contract; four hours
of home health aide service shall be considered as one home care visit.
(7) Every policy which provides coverage for in-patient hospital  care
shall  also  provide  coverage  for  pre-admission  tests  performed  in
hospital out-patient facilities prior to scheduled surgery provided:
(A) the tests are ordered by a physician as a planned  preliminary  to
admission  of  the  patient  as  an  in-patient  for surgery in the same
hospital;
(B) tests are necessary for and  consistent  with  the  diagnosis  and
treatment of the condition for which surgery is to be performed;
(C)  reservations  for  a hospital bed and for an operating room shall
have been made prior to the performance of the tests;
(D) the surgery  actually  takes  place  within  seven  days  of  such
presurgical tests; and
(E) the patient is physically present at the hospital for the tests.
(8)  Every policy which provides coverage for in-patient surgical care
shall include coverage for a second  surgical  opinion  by  a  qualified
physician on the need for surgery.
(9)(A) Every policy that provides coverage for inpatient hospital care
shall also include coverage for services to treat an emergency condition
in hospital facilities:
(i) without the need for any prior authorization determination;
(ii)  regardless  of  whether the health care provider furnishing such
services is a participating provider with respect to such services;
(iii)  if  the  emergency services are provided by a non-participating
provider, without imposing any administrative requirement or  limitation
on   coverage   that  is  more  restrictive  than  the  requirements  or
limitations that apply to emergency services received from participating
providers; and
(iv) if the emergency services are  provided  by  a  non-participating
provider,  the  cost-sharing  requirement  (expressed  as a copayment or
coinsurance) shall be the same requirement  that  would  apply  if  such
services were provided by a participating provider.
(B)  Any requirements of section 2719A(b) of the Public Health Service
Act, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed  the
requirements  of  this  paragraph  with respect to coverage of emergency
services shall be applicable to every policy subject to this paragraph.
(C) For purposes of this paragraph, an "emergency condition"  means  a
medical  or behavioral condition that manifests itself by acute symptoms
of sufficient severity, including  severe  pain,  such  that  a  prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably  expect  the absence of immediate medical attention to result
in (i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition  placing  the
health  of  such  person  or  others  in  serious jeopardy; (ii) serious
impairment to such person's bodily functions; (iii) serious  dysfunction
of  any  bodily organ or part of such person; (iv) serious disfigurement
of such person; or (v) a condition described  in  clause  (i),  (ii)  or
(iii) of section 1867(e)(1)(A) of the Social Security Act.
(D)  For  purposes of this paragraph, "emergency services" means, with
respect to an emergency condition: (i) a medical  screening  examination
as  required  under section 1867 of the Social Security Act, 42 U.S.C. §
1395dd, which is within the capability of the emergency department of  a
hospital,  including  ancillary  services  routinely  available  to  the
emergency department to evaluate such emergency medical  condition;  and
(ii)  within  the  capabilities of the staff and facilities available at
the hospital, such further medical  examination  and  treatment  as  are
required  under  section  1867  of  the Social Security Act, 42 U.S.C. §
1395dd, to stabilize the patient.
(E) For purposes of this paragraph, "to stabilize" means, with respect
to an emergency condition, to provide  such  medical  treatment  of  the
condition  as  may  be  necessary  to  assure, within reasonable medical
probability, that no material deterioration of the condition  is  likely
to  result  from  or  occur  during  the  transfer of the insured from a
facility or to deliver a newborn child (including the placenta).
(10) (A) (i) Every policy which provides hospital, surgical or medical
coverage shall provide coverage for maternity care, including  hospital,
surgical  or  medical care to the same extent that hospital, surgical or
medical coverage is provided for illness or disease  under  the  policy.
Such   maternity  care  coverage,  other  than  coverage  for  perinatal
complications, shall include inpatient hospital coverage for mother  and
for  newborn  for  at  least  forty-eight hours after childbirth for any
delivery other than a caesarean section, and  for  at  least  ninety-six
hours  after a caesarean section. Such coverage for maternity care shall
include the services of a  midwife  licensed  pursuant  to  article  one
hundred  forty  of the education law, practicing consistent with section
sixty-nine hundred fifty-one of the  education  law  and  affiliated  or
practicing  in  conjunction with a facility licensed pursuant to article
twenty-eight of the public health law, but no insurer shall be  required

to  pay  for  duplicative  routine  services actually provided by both a
licensed midwife and a physician.
(ii)  Maternity  care  coverage shall also include, at minimum, parent
education, assistance and training in breast or bottle feeding, and  the
performance of any necessary maternal and newborn clinical assessments.
(iii)  The  mother shall have the option to be discharged earlier than
the time periods established in item (i) of this subparagraph.  In  such
case,  the  inpatient  hospital  coverage must include at least one home
care visit, which shall be in addition to, rather than in lieu  of,  any
home  health  care  coverage available under the policy. The policy must
cover the home care visit which may be  requested  at  any  time  within
forty-eight  hours of the time of delivery (ninety-six hours in the case
of caesarean section) and shall be delivered within  twenty-four  hours,
(I)  after  discharge,  or  (II)  of  the  time of the mother's request,
whichever is later. Such home care coverage shall  be  pursuant  to  the
policy  and  subject  to  the  provisions  of this subparagraph, and not
subject to deductibles, coinsurance or copayments.
(B) Coverage provided under this  paragraph  for  care  and  treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.
(11) (A) Every policy that provides coverage for hospital, surgical or
medical  care  shall  provide  the  following  coverage  for mammography
screening for occult breast cancer:
(i) upon the recommendation of a physician, a mammogram, which may  be
provided  by breast tomosynthesis, at any age for covered persons having
a prior history of breast cancer or who have  a  first  degree  relative
with a prior history of breast cancer;
(ii)  a  single  baseline  mammogram,  which may be provided by breast
tomosynthesis, for covered persons aged thirty-five through thirty-nine,
inclusive; and
(iii)  an  annual  mammogram,  which  may  be   provided   by   breast
tomosynthesis, for covered persons aged forty and older.
(B) Such coverage required pursuant to subparagraph (A) or (C) of this
paragraph shall not be subject to annual deductibles or coinsurance.
(C)  For  purposes  of  subparagraphs  (A)  and (B) of this paragraph,
mammography screening means an X-ray examination  of  the  breast  using
dedicated  equipment,  including X-ray tube, filter, compression device,
screens, films and cassettes, with an average glandular  radiation  dose
less  than  0.5  rem  per  view  per  breast;  provided,  however,  that
mammography screening shall also include breast tomosynthesis.
(D) In addition to subparagraph (A), (B) or  (C)  of  this  paragraph,
every  policy  that  provides coverage for hospital, surgical or medical
care, except for a grandfathered health plan under subparagraph  (E)  of
this  paragraph,  shall  provide  coverage for the following mammography
screening services, and such coverage shall not  be  subject  to  annual
deductibles or coinsurance:
(i)  evidence-based  items  or  services  for mammography that have in
effect a rating of 'A' or 'B' in  the  current  recommendations  of  the
United States preventive services task force; and
(ii)  with  respect  to  women,  such  additional  preventive care and
screenings  for  mammography  not  described  in  item   (i)   of   this
subparagraph  and  as provided for in comprehensive guidelines supported
by the health resources and services administration.
(E) For purposes of this paragraph, "grandfathered health plan"  means
coverage  provided  by an insurer in which an individual was enrolled on
March twenty-third, two  thousand  ten  for  as  long  as  the  coverage

maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(F)  Screening  and  diagnostic  imaging  for  the detection of breast
cancer, including diagnostic mammograms, breast ultrasounds, or magnetic
resonance imaging, covered under the policy  shall  not  be  subject  to
annual deductibles or coinsurance.
(11-a) (A) Every policy delivered or issued for delivery in this state
which  provides  medical  coverage  that includes coverage for physician
services in a physician's office and every policy which  provides  major
medical  or  similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized  to  prescribe
under  title  eight  of  the  education  law, the following coverage for
diagnostic screening for prostatic cancer:
(i) standard diagnostic testing  including,  but  not  limited  to,  a
digital  rectal  examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and
(ii) an annual standard  diagnostic  examination  including,  but  not
limited to, a digital rectal examination and a prostate-specific antigen
test  for  men  age  fifty and over who are asymptomatic and for men age
forty and over with  a  family  history  of  prostate  cancer  or  other
prostate cancer risk factors.
(B)  Such  coverage  shall  not  be  subject  to annual deductibles or
coinsurance.
* (11-c) (A) Every policy which provides medical,  major  medical,  or
similar comprehensive-type coverage shall provide coverage for biomarker
precision  medical  testing for the purposes of diagnosis, treatment, or
appropriate management of, or  ongoing  monitoring  to  guide  treatment
decisions for, an insured's disease or condition when one or more of the
following  recognizes  the  efficacy  and  appropriateness  of biomarker
precision  medical  testing  for   diagnosis,   treatment,   appropriate
management,  or  guiding treatment decisions for an insured's disease or
condition:
(i) labeled indications for a test approved or cleared by the  federal
food  and  drug  administration  or  indicated tests for a food and drug
administration approved drug;
(ii) centers for medicare  and  medicaid  services  national  coverage
determinations  or  medicare  administrative  contractor  local coverage
determinations;
(iii) nationally recognized clinical practice guidelines; or
(iv) peer-reviewed literature  and  peer-reviewed  scientific  studies
published  in  or accepted for publication by medical journals that meet
nationally recognized requirements for scientific manuscripts  and  that
submit  most  of  their published articles for review by experts who are
not part of the editorial staff.
(B) Such coverage shall be provided  in  a  manner  that  shall  limit
disruptions  in  care  including  the  need  for  multiple  biopsies  or
biospecimen samples.
(C) As used in this paragraph, the  following  terms  shall  have  the
following meanings:
(i)  "Biomarker"  means  a  characteristic  that  is  measured  as  an
indicator of  normal  biological  processes,  pathogenic  processes,  or
responses   to   an  exposure  or  intervention,  including  therapeutic
interventions.
(ii) "Biomarker precision medical testing" means  the  analysis  of  a
patient's  tissue,  blood,  or  other  biospecimen for the presence of a
biomarker.  Biomarker  testing  includes   but   is   not   limited   to
single-analyte   tests   and  multi-plex  panel  tests  performed  at  a

participating  in-network  laboratory  facility  that  is  either   CLIA
certified or CLIA waived by the federal food and drug administration.
(iii)  "Nationally  recognized  clinical  practice  guidelines"  means
evidence-based clinical practice guidelines  informed  by  a  systematic
review  of  evidence  and  an  assessment  of the benefits, and risks of
alternative care options intended to optimize patient care developed  by
independent  organizations or medical professional societies utilizing a
transparent methodology and reporting structure and with a  conflict  of
interest policy.
* NB Effective January 1, 2025
(12)  (A)  Every  policy  which provides coverage for prescribed drugs
approved by the food  and  drug  administration  of  the  United  States
government  for  the  treatment  of  certain  types  of cancer shall not
exclude coverage of any such drug on the basis that such drug  has  been
prescribed  for the treatment of a type of cancer for which the drug has
not been  approved  by  the  food  and  drug  administration.  Provided,
however, that such drug must be recognized for treatment of the specific
type  of  cancer  for  which  the drug has been prescribed in one of the
following established reference compendia:
(i)  the  American   Hospital   Formulary   Service-Drug   Information
(AHFS-DI);
(ii)  National  Comprehensive  Cancer  Networks  Drugs  and  Biologics
Compendium;
(iii) Thomson Micromedex DrugDex;
(iv)  Elsevier  Gold  Standard's  Clinical  Pharmacology;   or   other
authoritative compendia as identified by the Federal Secretary of Health
and  Human  Services  or  the  Centers  for Medicare & Medicaid Services
(CMS); or recommended by review article or editorial comment in a  major
peer reviewed professional journal.
(B)  Notwithstanding  the provisions of this paragraph, coverage shall
not be required for any experimental or  investigational  drugs  or  any
drug  which  the  food  and  drug  administration  has  determined to be
contraindicated for treatment of the specific type of cancer  for  which
the  drug  has  been  prescribed. The provisions of this paragraph shall
apply to cancer drugs only and nothing  herein  shall  be  construed  to
create,  impair,  alter,  limit,  modify,  enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any  other  disease  or
condition.
(12-a) (A) Every policy delivered or issued for delivery in this state
that  provides  medical,  major  medical,  or similar comprehensive-type
coverage and provides coverage for prescription drugs and also  provides
coverage  for  cancer  chemotherapy treatment shall provide coverage for
prescribed, orally administered anticancer medications used to  kill  or
slow  the  growth  of  cancerous  cells. Such coverage may be subject to
co-pays,  coinsurance  or  deductibles,  provided  that   the   co-pays,
coinsurance  or  deductibles  are at least as favorable to an insured as
the co-pays, coinsurance or  deductibles  that  apply  to  coverage  for
intravenous or injected anticancer medications.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) vary the terms of the policy for the purpose or with the effect of
avoiding compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph; or
(v)  achieve compliance with this paragraph by imposing an increase in
cost sharing for an intravenous or injected anticancer medication.
(13) (A) Every policy which provides coverage for hospital care  shall
not  exclude  coverage  for hospital care for diagnosis and treatment of
correctable medical conditions otherwise covered by  the  policy  solely
because the medical condition results in infertility.
(B) Every policy which provides coverage for surgical and medical care
shall  not  exclude coverage for surgical and medical care for diagnosis
and treatment of correctable medical conditions otherwise covered by the
policy solely because the medical condition results in infertility.
(C) Every policy that  provides  medical,  major  medical  or  similar
comprehensive-type   coverage   shall   provide  coverage  for  standard
fertility preservation services when a medical treatment may directly or
indirectly cause iatrogenic infertility to an insured. Coverage  may  be
subject  to annual deductibles and coinsurance, including copayments, as
may be deemed appropriate by the superintendent and  as  are  consistent
with those established for other benefits within a given policy.
(i)  For purposes of this subparagraph, "iatrogenic infertility" means
an impairment of fertility by surgery, radiation, chemotherapy or  other
medical treatment affecting reproductive organs or processes.
(ii)   No  insurer  providing  coverage  under  this  paragraph  shall
discriminate based on an insured's expected length of life,  present  or
predicted disability, degree of medical dependency, perceived quality of
life, or other health conditions, nor based on personal characteristics,
including  age,  sex,  sexual  orientation,  marital  status  or  gender
identity.
(13-a) Every policy that provides coverage for prescription  fertility
drugs and requires or permits prescription drugs to be purchased through
a  network  participating  mail order or other non-retail pharmacy shall
provide the same coverage for prescription  fertility  drugs  when  such
drugs  are  purchased from a network participating non-mail order retail
pharmacy provided that the network participating non-mail  order  retail
pharmacy  agrees  in advance through a contractual network agreement, to
the same reimbursement amount, as well as the same applicable terms  and
conditions, that the insurer has established for a network participating
mail  order or other non-retail pharmacy. In such case, the policy shall
not impose  any  fee,  co-payment,  co-insurance,  deductible  or  other
condition  on  any insured who elects to purchase prescription fertility
drugs through a network participating  non-mail  order  retail  pharmacy
that  it  does  not  impose  on  any  insured who purchases prescription
fertility drugs through a network  participating  mail  order  or  other
non-retail pharmacy.
(14)  If  a  policy  provides  for  reimbursement  for the services of
licensed health professionals who can bill  for  services,  the  insured
shall be entitled to reimbursement for such service provided pursuant to
a clinical practice plan established pursuant to subdivision fourteen of
section two hundred six of the public health law.
(15) (A) Every policy that provides hospital, surgical or medical care
coverage or provides reimbursement for laboratory tests or reimbursement
for  diagnostic  X-ray  services  shall  provide  coverage for an annual

cervical cytology screening for cervical cancer and its precursor states
for women aged eighteen and older.
(B)  For  purposes  of  subparagraphs  (A)  and (C) of this paragraph,
cervical cytology screening shall include an annual pelvic  examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services  provided  in  connection with examining and evaluating the Pap
smear.
(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.
(D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
every policy that provides hospital, surgical or medical care  coverage,
except  for  a  grandfathered health plan under subparagraph (E) of this
paragraph, shall provide coverage for the  following  cervical  cytology
screening  services,  and  such  coverage shall not be subject to annual
deductibles or coinsurance:
(i) evidence-based items or services for cervical cytology  that  have
in  effect  a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(ii) with respect  to  women,  such  additional  preventive  care  and
screenings  for  cervical  cytology  not  described  in item (i) of this
subparagraph and as provided for in comprehensive  guidelines  supported
by the health resources and services administration.
(E)  For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was  enrolled  on
March  twenty-third,  two  thousand  ten  for  as  long  as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(15-a) (A) Every policy which provides medical coverage that  includes
coverage for physician services in a physician's office and every policy
which  provides  major  medical  or  similar comprehensive-type coverage
shall include coverage for the following equipment and supplies for  the
treatment  of  diabetes,  if recommended or prescribed by a physician or
other licensed health care  provider  legally  authorized  to  prescribe
under title eight of the education law: blood glucose monitors and blood
glucose  monitors  for  the  visually impaired, data management systems,
test strips for glucose monitors and visual reading  and  urine  testing
strips,  insulin,  injection aids, cartridges for the visually impaired,
syringes, insulin pumps  and  appurtenances  thereto,  insulin  infusion
devices,  and  oral agents for controlling blood sugar. In addition, the
commissioner of the department of health shall provide and  periodically
update by rule or regulation a list of additional diabetes equipment and
related  supplies  such  as are medically necessary for the treatment of
diabetes, for which there shall also be coverage.  Such  policies  shall
also  include  coverage for diabetes self-management education to ensure
that persons with diabetes are educated as to the proper self-management
and treatment of their  diabetic  condition,  including  information  on
proper  diets. Such coverage for self-management education and education
relating to diet shall be limited to visits medically necessary upon the
diagnosis of diabetes, where a physician diagnoses a significant  change
in  the  patient's symptoms or conditions which necessitate changes in a
patient's self-management, or where reeducation or  refresher  education
is  necessary.  Such education may be provided by the physician or other
licensed health care provider  legally  authorized  to  prescribe  under
title  eight  of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by  a  certified  diabetes
nurse   educator,   certified   nutritionist,   certified  dietitian  or

registered dietitian upon the referral of a physician or other  licensed
health  care  provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator,  certified  nutritionist,  certified  dietitian  or registered
dietitian  may  be  limited  to  group  settings  wherever  practicable.
Coverage  for  self-management  education and education relating to diet
shall also include home visits when medically necessary.
* (B)  Such  coverage  may  be  subject  to  annual  deductibles   and
coinsurance  as  may  be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a  given
policy;  provided  however,  the  total  amount that a covered person is
required to pay out of pocket for  covered  prescription  insulin  drugs
shall  be  capped  at  an  amount  not to exceed one hundred dollars per
thirty-day supply, regardless of the amount or type of insulin needed to
fill such covered person's prescription and regardless of the  insured's
deductible,   copayment,   coinsurance   or   any   other  cost  sharing
requirement.
* NB Effective until January 1, 2025
* (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, that covered prescription insulin drugs shall
not be subject to a deductible, copayment, coinsurance or any other cost
sharing requirement.
* NB Effective January 1, 2025
(16)  If  a  policy  provides  for  reimbursement  for speech-language
pathology or audiology service which  is  within  the  lawful  scope  of
practice  of a duly licensed speech-language pathologist or audiologist,
an insured shall be entitled to reimbursement for such  service  whether
the   said  service  is  performed  by  a  physician  or  duly  licensed
speech-language  pathologist  or  audiologist,  provided  however,  that
nothing  contained herein shall be construed to impair any terms of such
policy which may require said service to  be  performed  pursuant  to  a
medical  order, or a similar or related service of a physician, in which
case coverage need  not  be  provided  for  any  tests,  evaluations  or
diagnoses  if  such  tests,  evaluations  or diagnoses have already been
provided by or through a physician within twelve months of the  referral
or  order from the physician. However, nothing herein shall be construed
as preventing an insurer from covering more than one test or  evaluation
provided  by  a  speech-language  pathologist  or  audiologist  within a
twelve-month period where such  test  or  evaluation  is  ordered  by  a
physician as medically necessary. Nor shall anything herein be construed
as  prohibiting  the  limitation  of  such  services,  where covered, to
specified settings other than offices, such as hospitals or to  services
provided by such professionals as part of a home care agency's services.
(17)  (A) Every policy that provides medical, major-medical or similar
comprehensive-type coverage shall provide coverage for the provision  of
preventive and primary care services.
(B)  For  the  purposes  of  subparagraphs  (A),  (C)  and (D) of this
paragraph, preventive and primary  care  services  means  the  following
services  rendered  to  a  covered  child of an insured from the date of
birth through the attainment of nineteen years;
(i) an initial hospital check-up and well-child  visits  scheduled  in
accordance   with  the  prevailing  clinical  standards  of  a  national
association of pediatric physicians designated by  the  commissioner  of
health  (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service  other  than  the
limits  under  state  law). Coverage for such services rendered shall be

provided only to the extent that such services are provided by or  under
the  supervision  of  a  physician, or other professional licensed under
article one hundred thirty-nine of the  education  law  whose  scope  of
practice  pursuant  to  such  law  includes the authority to provide the
specified  services.  Coverage  shall  be  provided  for  such  services
rendered  in  a hospital, as defined in section twenty-eight hundred one
of the public health law, or in  an  office  of  a  physician  or  other
professional  licensed  under  article  one  hundred  thirty-nine of the
education law whose scope of practice pursuant to such law includes  the
authority to provide the specified services;
(ii)  at  each  visit,  services  in  accordance  with  the prevailing
clinical standards of such designated association, including  a  medical
history,  a  complete  physical  examination,  developmental assessment,
anticipatory guidance, appropriate immunizations  and  laboratory  tests
which  tests  are  ordered at the time of the visit and performed in the
practitioner's  office,  as  authorized  by  law,  or  in   a   clinical
laboratory; and
(iii)  necessary immunizations, as determined by the superintendent in
consultation with the commissioner of health,  consisting  of  at  least
adequate  dosages  of  vaccine  against  diphtheria, pertussis, tetanus,
polio, measles,  rubella,  mumps,  haemophilus  influenzae  type  b  and
hepatitis  b,  which  meet  the  standards approved by the United States
public health service for such biological products.
(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not be subject to annual deductibles or coinsurance.
(D) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not restrict or eliminate existing coverage provided  by
the policy.
(E)  In  addition  to  subparagraph  (A),  (B),  (C)  or  (D)  of this
paragraph, every policy that provides hospital, surgical or medical care
coverage, except for a grandfathered health plan under subparagraph  (F)
of  this  paragraph, shall provide coverage for the following preventive
care and screenings for insureds, and such coverage shall not be subject
to annual deductibles or coinsurance:
(i)  evidence-based  items  or  services  for  preventive   care   and
screenings  that  have  in  effect a rating of 'A' or 'B' in the current
recommendations of the United States preventive services task force;
(ii) immunizations that have  in  effect  a  recommendation  from  the
advisory  committee on immunization practices of the centers for disease
control and prevention with respect to the individual involved;
(iii) with respect to children,  including  infants  and  adolescents,
evidence-informed   preventive  care  and  screenings  provided  for  in
comprehensive guidelines supported by the health resources and  services
administration; and
(iv)  with  respect  to  women,  such  additional  preventive care and
screenings not described  in  item  (i)  of  this  subparagraph  and  as
provided  for  in  comprehensive  guidelines  supported  by  the  health
resources and services administration.
(v) all FDA-approved contraceptive drugs, devices, and other products,
including  all  over-the-counter  contraceptive  drugs,   devices,   and
products as prescribed or as otherwise authorized under state or federal
law;  voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and
identified in the  comprehensive  guidelines  supported  by  the  health
resources  and  services  administration and thereby incorporated in the
essential  health  benefits  benchmark  plan;  patient   education   and
counseling  on  contraception;  and  follow-up  services  related to the
drugs, devices, products, and  procedures  covered  under  this  clause,
including,  but  not  limited to, management of side effects, counseling

for continued adherence, and device insertion  and  removal.  Except  as
otherwise  authorized under this clause, a contract shall not impose any
restrictions or delays on  the  coverage  required  under  this  clause.
However,  where  the  FDA  has  approved  one  or  more  therapeutic and
pharmaceutical  equivalent,  as  defined  by  the  FDA,  versions  of  a
contraceptive  drug,  device,  or product, a contract is not required to
include all such therapeutic and pharmaceutical equivalent  versions  in
its  formulary,  so long as at least one is included and covered without
cost-sharing  and  in  accordance  with  this  clause.  If  the  covered
therapeutic and pharmaceutical equivalent versions of a drug, device, or
product are not available or are deemed medically inadvisable a contract
shall  provide  coverage for an alternate therapeutic and pharmaceutical
equivalent version of the contraceptive drug, device, or product without
cost-sharing. (a) This coverage shall  include  emergency  contraception
without  cost sharing when provided pursuant to a prescription, or order
under section sixty-eight hundred thirty-one of  the  education  law  or
when  lawfully  provided  over-the-counter.  (b) If the attending health
care  provider,  in  his  or  her  reasonable   professional   judgment,
determines  that  the use of a non-covered therapeutic or pharmaceutical
equivalent of a drug, device, or product is warranted, the  health  care
provider's  determination  shall  be  final.  The  superintendent  shall
promulgate regulations establishing a process, including timeframes, for
an insured, an insured's designee or an insured's health  care  provider
to  request  coverage  of  a  non-covered contraceptive drug, device, or
product. Such regulations shall include a requirement that insurers  use
an   exception   form  that  shall  meet  criteria  established  by  the
superintendent. (c) This coverage must allow for the dispensing of up to
twelve months worth of a contraceptive at one time. (d) For the purposes
of this clause, "over-the-counter  contraceptive  products"  shall  mean
those products provided for in comprehensive guidelines supported by the
health resources and services administration as of January twenty-first,
two thousand nineteen.
(F)  For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was  enrolled  on
March  twenty-third,  two  thousand  ten  for  as  long  as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(18) (A) Every policy which provides coverage for  inpatient  hospital
care shall provide such coverage for such period as is determined by the
attending  physician  in  consultation  with the patient to be medically
appropriate for such covered person undergoing a lymph  node  dissection
or  a  lumpectomy  for  the  treatment  of breast cancer or a mastectomy
covered  by  the  policy.  Such  coverage  may  be  subject  to   annual
deductibles  and  coinsurance  as  may  be  deemed  appropriate  by  the
superintendent and as are consistent with those  established  for  other
benefits  within  a  given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to  inception
of such policy and annually thereafter.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll  or  to  renew coverage under the terms of the policy or vary the
terms of the policy for the purpose  or  with  the  effect  of  avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph; or
(v)  restrict  coverage  for any portion of a period within a hospital
length of stay required under  this  paragraph  in  a  manner  which  is
inconsistent  with  the  coverage  provided for any preceding portion of
such stay.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the  provisions  of  sections  three  thousand  two  hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing  in  this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(19) (A) Every  policy  which  provides  medical,  major  medical,  or
similar  comprehensive-type  coverage must provide coverage for a second
medical opinion by an appropriate specialist, including but not  limited
to  a  specialist  affiliated  with  a  specialty  care  center  for the
treatment of cancer, in the event of a positive or negative diagnosis of
cancer or a recurrence of cancer or a  recommendation  of  a  course  of
treatment for cancer, subject to the following:
(i)  In  the  case  of  a  policy that requires, or provides financial
incentives for, the insured to receive covered services from health care
providers participating in a provider network  maintained  by  or  under
contract  with  the  insurer,  the  policy  shall include coverage for a
second medical opinion from a  non-participating  specialist,  including
but  not limited to a specialist affiliated with a specialty care center
for the treatment of cancer, when the  attending  physician  provides  a
written  referral  to  a  non-participating specialist, at no additional
cost to the insured  beyond  what  such  insured  would  have  paid  for
services  from  a participating appropriate specialist. Provided however
that nothing herein shall impair an insured's rights (if any) under  the
policy  to  obtain  the  second medical opinion from a non-participating
specialist without  a  written  referral,  subject  to  the  payment  of
additional  coinsurance  (if  any)  required  by the policy for services
provided by non-participating providers. The  insurer  shall  compensate
the  non-participating specialist at the usual, customary and reasonable
rate, or at a rate listed on a fee schedule filed and  approved  by  the
superintendent which provides a comparable level of reimbursement.
(ii)  In  the  case  of  a  policy  that  does  not  provide financial
incentives for, and does not require, the  insured  to  receive  covered
services  from health care providers participating in a provider network
maintained by or under contract  with  the  insurer,  the  policy  shall
include  coverage  for  a second medical opinion from a specialist at no
additional cost to the insured beyond what the insured would  have  paid
for comparable services covered under the policy.
(iii)   Such  coverage  may  be  subject  to  annual  deductibles  and
coinsurance as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
policy, and, where applicable, consistent with the provisions of clauses
(i) and (ii) of this subparagraph.
Nothing in this paragraph shall eliminate  or  diminish  an  insurer's
obligation  to comply with the provisions of section four thousand eight
hundred four of this chapter where applicable.  Written  notice  of  the

availability  of  such  coverage  shall be delivered to the policyholder
prior to the inception of such policy and annually thereafter.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll  or  to  renew coverage under the terms of the policy or vary the
terms of the policy for the purpose  or  with  the  effect  of  avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph; or
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition  to  the  provisions  of  sections  three  thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to  suspend,  supersede,
amend or otherwise modify such sections.
(20)  (A)  Every  policy  which  provides  medical,  major medical, or
similar comprehensive-type coverage shall provide the following coverage
for breast or chest wall reconstruction surgery after  a  mastectomy  or
partial mastectomy:
(i)  all stages of reconstruction of the breast or chest wall on which
the mastectomy or partial mastectomy has been performed; and
(ii) surgery and reconstruction of the other breast or chest  wall  to
produce a symmetrical appearance;
in  the  manner determined by the attending physician and the patient to
be  appropriate.  Chest  wall  reconstruction  surgery   shall   include
aesthetic  flat  closure  as such term is defined by the National Cancer
Institute. Such coverage  may  be  subject  to  annual  deductibles  and
coinsurance   provisions   as   may   be   deemed   appropriate  by  the
superintendent and as are consistent with those  established  for  other
benefits  within  a  given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to  inception
of such policy and annually thereafter.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll  or  to  renew coverage under the terms of the policy or vary the
terms of the policy for the purpose  or  with  the  effect  of  avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such

practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph; or
(v)  restrict  coverage  for any portion of a period within a hospital
length of stay required under  this  paragraph  in  a  manner  which  is
inconsistent  with  the  coverage  provided for any preceding portion of
such stay.
(C) The prohibitions in this paragraph shall be  in  addition  to  the
provisions  of  sections three thousand two hundred thirty-one and three
thousand two hundred thirty-two of this  article  and  nothing  in  this
paragraph  shall  be construed to suspend, supersede, amend or otherwise
modify such sections.
* (21) Every policy that  provides  coverage  for  prescription  drugs
shall  include  coverage  for the cost of enteral formulas for home use,
whether administered orally or via tube feeding, for which  a  physician
or  other  licensed health care provider legally authorized to prescribe
under title eight of the education law has issued a written order.  Such
written  order shall state that the enteral formula is clearly medically
necessary and has been proven effective as a disease-specific  treatment
regimen. Specific diseases and disorders for which enteral formulas have
been  proven  effective shall include, but are not limited to, inherited
diseases of amino acid or  organic  acid  metabolism;  Crohn's  Disease;
gastroesophageal  reflux; disorders of gastrointestinal motility such as
chronic  intestinal  pseudo-obstruction;  and  multiple,   severe   food
allergies   including,   but   not   limited  to  immunoglobulin  E  and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders; and
impaired absorption of  nutrients  caused  by  disorders  affecting  the
absorptive    surface,   function,   length,   and   motility   of   the
gastrointestinal tract. Enteral formulas that  are  medically  necessary
and  taken  under  written  order  from a physician for the treatment of
specific diseases shall be distinguished  from  nutritional  supplements
taken  electively. Coverage for certain inherited diseases of amino acid
and  organic  acid  metabolism  as  well  as  severe  protein   allergic
conditions  shall  include  modified  solid  food  products that are low
protein, contain modified protein, or are  amino  acid  based  that  are
medically necessary.
* NB There are 2 par (21)'s
* (21)(A) Every policy which is a "managed care product" as defined in
subparagraph  (D) of this paragraph that provides coverage for physician
services in a physician's office, and every policy which is  a  "managed
care  product" that provides major medical or similar comprehensive-type
coverage, shall include coverage for chiropractic care,  as  defined  in
section  six  thousand  five  hundred  fifty-one  of  the education law,
provided by a doctor of chiropractic licensed pursuant  to  article  one
hundred  thirty-two  of  the  education  law,  in  connection  with  the
detection or correction by manual  or  mechanical  means  of  structural
imbalance,  distortion  or subluxation in the human body for the purpose
of removing nerve interference, and  the  effects  thereof,  where  such
interference  is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column.  However,  chiropractic  care
and  services  may  be  subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits,  and  reasonable
utilization  review,  provided that any such amounts, limits and review:
(a) shall not function to direct treatment in  a  manner  discriminative
against  chiropractic  care, and (b) individually and collectively shall
be no more restrictive than those applicable under the  same  policy  to
care   or  services  provided  by  other  health  professionals  in  the
diagnosis, treatment and management of the same or  similar  conditions,

injuries,   complaints,   disorders   or  ailments,  even  if  differing
nomenclature is used  to  describe  the  condition,  injury,  complaint,
disorder  or  ailment.  Nothing  herein  contained shall be construed as
impeding  or preventing either the provision or coverage of chiropractic
care and services by duly licensed doctors of chiropractic,  within  the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.
(C)  Every  policy which includes coverage for physician services in a
physician's office, and every policy which  provides  major  medical  or
similar comprehensive-type coverage, other than a "managed care product"
as defined in subparagraph (D) of this paragraph, shall provide coverage
for  chiropractic  care, as defined in section six thousand five hundred
fifty-one of the education law, provided by  a  doctor  of  chiropractic
licensed  pursuant  to  article  one hundred thirty-two of the education
law, in connection  with  the  detection  or  correction  by  manual  or
mechanical  means  of structural imbalance, distortion or subluxation in
the human body for the purpose of removing nerve interference,  and  the
effects  thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of or in the  vertebral  column.
However,  chiropractic  care  and  services may be subject to reasonable
deductible, co-payment  and  co-insurance  amounts,  reasonable  fee  or
benefit  limits,  and  reasonable  utilization review, provided that any
such amounts, limits and  review:  (a)  shall  not  function  to  direct
treatment  in a manner discriminative against chiropractic care, and (b)
individually and collectively shall be no more  restrictive  than  those
applicable  under  the same policy to care or services provided by other
health professionals in the diagnosis, treatment and management  of  the
same or similar conditions, injuries, complaints, disorders or ailments,
even  if  differing  nomenclature  is  used  to  describe the condition,
injury, complaint, disorder or ailment. Nothing herein  contained  shall
be  construed as impeding or preventing either the provision or coverage
of  chiropractic  care  and  services  by  duly  licensed   doctors   of
chiropractic,  within  the  lawful  scope  of  chiropractic practice, in
hospital facilities on a staff or employee basis.
(D) For purposes of this paragraph, a  "managed  care  product"  shall
mean  a policy which requires that medical or other health care services
covered under  the  policy,  other  than  emergency  care  services,  be
provided  by,  or  pursuant to a referral from, a primary care provider,
and that services provided pursuant to such a referral be rendered by  a
health  care  provider  participating  in  the  insurer's  managed  care
provider network. In addition, a managed care product  shall  also  mean
the  in-network  portion  of  a  contract which requires that medical or
other health care  services  covered  under  the  contract,  other  than
emergency care services, be provided by, or pursuant to a referral from,
a  primary  care provider, and that services provided pursuant to such a
referral be rendered by a health  care  provider  participating  in  the
insurer's  managed care provider network, in order for the insured to be
entitled to the maximum reimbursement under the contract.
(E) The coverage required by this paragraph shall not be  abridged  by
any regulation promulgated by the superintendent.
* NB There are 2 par (21)'s
(22)  No  policy  shall  exclude coverage of a health care service, as
defined in paragraph two of subsection (e) of section four thousand nine
hundred of this chapter, rendered or  proposed  to  be  rendered  to  an
insured   on   the   basis   that   such   service  is  experimental  or
investigational, is rendered as part of a clinical trial as  defined  in
subsection  (b-2)  of  section  forty-nine hundred of this chapter, or a
prescribed pharmaceutical product  referenced  in  subparagraph  (B)  of

paragraph  two  of  subsection (e) of section forty-nine hundred of this
chapter provided that coverage of the patient costs of such service  has
been  recommended  for  the  insured by an external appeal agent upon an
appeal  conducted  pursuant  to  subparagraph  (B)  of paragraph four of
subsection (b) of section four thousand nine hundred  fourteen  of  this
chapter. The determination of the external appeal agent shall be binding
on the parties. For purposes of this paragraph, patient costs shall have
the  same  meaning  as such term has for purposes of subparagraph (B) of
paragraph four of subsection (b) of section four thousand  nine  hundred
fourteen  of  this  chapter;  provided,  however,  that coverage for the
services required under this paragraph shall be provided subject to  the
terms  and  conditions  generally  applicable to other benefits provided
under the policy.
(23)  If  a  policy  provides  for  reimbursement  for  physical   and
occupational  therapy  service  which  is  within  the  lawful  scope of
practice of a duly  licensed  physical  or  occupational  therapist,  an
insured  shall be entitled to reimbursement for such service whether the
said service is performed by a physician  or  through  a  duly  licensed
physical  or  occupational  therapist,  provided  however,  that nothing
contained herein shall be construed to impair any terms of  such  policy
including  appropriate  utilization review and the requirement that said
service be performed pursuant to  a  medical  order,  or  a  similar  or
related service of a physician.
(24)(A)   Every   policy  which  provides  major  medical  or  similar
comprehensive-type  coverage  shall  include  coverage  for  prehospital
emergency  medical  services for the treatment of an emergency condition
when such services  are  provided  by  an  ambulance  service  issued  a
certificate  to  operate  pursuant to section three thousand five of the
public health law.
(B) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against an insured for the services  provided  pursuant  to
this  paragraph, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms  of
the policy.
* (C)  An  insurer  shall  provide  reimbursement  for  those services
prescribed by this section at rates negotiated between the  insurer  and
the  provider  of such services. In the absence of agreed upon rates, an
insurer shall pay for such services at the usual and  customary  charge,
which shall not be excessive or unreasonable.
* NB Effective until January 1, 2025
* (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. The insurer shall send
such payments directly to the provider of such  ambulance  services,  if
the  ambulance  service  has  on file an executed assignment of benefits
form with the claim.
* NB Effective January 1, 2025
* (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.
* NB Effective until January 1, 2025
* (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
unless such services are covered under the policy.
* NB Effective January 1, 2025
(E) As used in this paragraph:
(i)   "Prehospital   emergency  medical  services"  means  the  prompt
evaluation and treatment  of  an  emergency  medical  condition,  and/or
non-air-borne  transportation  of  the  patient  to a hospital, provided
however,   where   the   patient   utilizes   non-air-borne    emergency
transportation  pursuant to this paragraph, reimbursement shall be based
on whether a prudent  layperson,  possessing  an  average  knowledge  of
medicine  and  health,  could  reasonably  expect  the  absence  of such
transportation to result  in  (I)  placing  the  health  of  the  person
afflicted  with  such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of  such  person  or  others  in
serious  jeopardy;  (II)  serious  impairment  to  such  person's bodily
functions; (III) serious dysfunction of any bodily organ or part of such
person; (IV) serious disfigurement of such person; or  (V)  a  condition
described  in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the
Social Security Act.
(ii) "Emergency condition" means a  medical  or  behavioral  condition
that   manifests  itself  by  acute  symptoms  of  sufficient  severity,
including severe pain, such that  a  prudent  layperson,  possessing  an
average  knowledge  of  medicine and health, could reasonably expect the
absence of immediate medical attention to  result  in  (I)  placing  the
health  of the person afflicted with such condition in serious jeopardy,
or in the case of a behavioral condition  placing  the  health  of  such
person  or  others  in serious jeopardy; (II) serious impairment to such
person's bodily functions; (III) serious dysfunction of any bodily organ
or part of such person; (IV) serious disfigurement of  such  person;  or
(V)  a  condition  described  in  clause  (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
(25) (A) Every policy which provides coverage for hospital or surgical
coverage  shall  not  exclude  coverage  for  screening,  diagnosis  and
treatment  of  medical conditions otherwise covered by the policy solely
because the treatment is provided to diagnose or treat  autism  spectrum
disorder.
(B)  Every  policy  that  provides  physician services, medical, major
medical or similar comprehensive-type coverage  shall  provide  coverage
for  the  screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening,  diagnosis  or  treatment  of  medical  conditions  otherwise
covered  by  the  policy because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to  annual  deductibles,
copayments   and  coinsurance  as  may  be  deemed  appropriate  by  the
superintendent and shall be  consistent  with  those  imposed  on  other
benefits  under  the  policy.  This  paragraph shall not be construed as
limiting the benefits that are  otherwise  available  to  an  individual
under  the  policy,  provided however that such policy shall not contain
any limitations on visits that are solely applied to  the  treatment  of
autism  spectrum disorder. No insurer shall terminate coverage or refuse
to deliver, execute, issue, amend,  adjust,  or  renew  coverage  to  an
individual  solely  because  the  individual  is  diagnosed  with autism
spectrum  disorder  or  has  received  treatment  for  autism   spectrum
disorder.  Coverage  shall be subject to utilization review and external
appeals of health care services pursuant to article forty-nine  of  this
chapter as well as case management and other managed care provisions.
(C) For purposes of this paragraph:
(i)  "autism  spectrum  disorder"  means  any  pervasive developmental
disorder as defined in the most recent edition  of  the  diagnostic  and
statistical manual of mental disorders.
(ii) "applied behavior analysis" means the design, implementation, and
evaluation  of environmental modifications, using behavioral stimuli and
consequences, to  produce  socially  significant  improvement  in  human
behavior,  including  the  use  of  direct observation, measurement, and
functional  analysis  of  the  relationship  between   environment   and
behavior.
(iii)  "behavioral  health  treatment"  means counseling and treatment
programs, when provided by a licensed  provider,  and  applied  behavior
analysis,  when  provided  by  a person licensed, certified or otherwise
authorized to provide applied behavior analysis, that are  necessary  to
develop,  maintain,  or  restore, to the maximum extent practicable, the
functioning of an individual.
(iv)  "diagnosis  of  autism  spectrum  disorder"  means  assessments,
evaluations,  or  tests  to  diagnose  whether  an individual has autism
spectrum disorder.
(v) "pharmacy care" means medications prescribed by a licensed  health
care  provider  legally authorized to prescribe under title eight of the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed  in  the  state  in  which  the  psychiatrist
practices.
(vii)  "psychological  care"  means  direct  or  consultative services
provided  by  a  psychologist  licensed  in  the  state  in  which   the
psychologist practices.
(viii)  "therapeutic  care"  means  services  provided  by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(ix)  "treatment  of  autism  spectrum  disorder"  shall  include  the
following care and assistive communication devices prescribed or ordered
for  an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:
(1) behavioral health treatment;
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
(5) therapeutic care,  including  therapeutic  care  which  is  deemed
habilitative  or  nonrestorative,  in the event that the policy provides
coverage for therapeutic care; and
(6) pharmacy care in the event that the policy provides  coverage  for
prescription drugs.
(D)  Coverage  may be denied on the basis that such treatment is being
provided to the covered person pursuant to an  individualized  education
plan  under  article  eighty-nine of the education law. The provision of
services pursuant to an individualized family service plan under section
twenty-five  hundred  forty-five  of   the   public   health   law,   an
individualized education plan under article eighty-nine of the education
law,  or  an  individualized service plan pursuant to regulations of the
office for persons with  developmental  disabilities  shall  not  affect
coverage  under the policy for services provided on a supplemental basis
outside of an educational setting if such services are prescribed  by  a
licensed physician or licensed psychologist.
(E)  Nothing  in  this  paragraph  shall  be  construed  to affect any
obligation to provide services to an individual under an  individualized
family  service plan under section twenty-five hundred forty-five of the
public health  law,  an  individualized  education  plan  under  article

eighty-nine  of  the  education  law,  or an individualized service plan
pursuant to regulations of the office  for  persons  with  developmental
disabilities.
(G)  Nothing  in this paragraph shall be construed to prevent a policy
from providing services through a network of participating providers who
shall meet certain requirements for  participation,  including  provider
credentialing.
(H)   Coverage   under   this  paragraph  shall  not  apply  financial
requirements  or  treatment  limitations  to  autism  spectrum  disorder
benefits  that  are  more  restrictive  than  the  predominant financial
requirements and treatment  limitations  applied  to  substantially  all
medical and surgical benefits covered by the policy.
(I) The criteria for medical necessity determinations under the policy
with  respect  to  autism  spectrum  disorder  benefits  shall  be  made
available by  the  insurer  to  any  insured,  prospective  insured,  or
in-network provider upon request.
(J) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement; and
(iii)  "treatment  limitation"  means  limits  on  the  frequency   of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy.
(K)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
(26)(A) No managed care health insurance policy that provides coverage
for hospital, medical or surgical care shall provide that services of  a
participating hospital will be covered as out-of-network services solely
on  the  basis  that  the  health  care  provider admitting or rendering
services to the insured is not a participating provider.
(B) No managed care health insurance policy that provides coverage for
hospital, medical or surgical care shall  provide  that  services  of  a
participating  health  care  provider  will be covered as out-of-network
services solely on the  basis  that  the  services  are  rendered  in  a
non-participating hospital.
(C)  For  purposes  of  this  paragraph, a "health care provider" is a
health care professional licensed, registered or certified  pursuant  to
title  eight  of  the  education  law  or  a  health  care  professional
comparably licensed, registered or certified by another state.
(D) For purposes of this paragraph, a "managed care  health  insurance
policy"  is  a  policy  that  requires  that  services  be provided by a
provider participating in the insurer's network in order for the insured
to receive the maximum level of reimbursement under the policy.
(27) No policy delivered or issued for delivery in  this  state  which
provides  coverage  for  prescription  drugs and for which cost-sharing,
deductibles or co-insurance obligations are determined  by  category  of
prescription   drugs   shall   impose   cost-sharing,   deductibles   or
co-insurance  obligations  for  any  prescription  drug that exceeds the
dollar amount of cost-sharing, deductibles or  co-insurance  obligations
for non-preferred brand drugs or its equivalent (or brand drugs if there
is no non-preferred brand drug category).
(28)  Notwithstanding  title  eleven  of  article  five  of the social
services law or any other  law  to  the  contrary,  every  policy  which
provides  coverage for prescription drugs shall, with regard to eye drop
medication requiring a  prescription  that  has  been  approved  by  the
insurer   for   coverage,   allow  for  the  limited  refilling  of  the
prescription prior to the last day of the approved dosage period without
regard to  any  coverage  restrictions  on  early  refill  of  renewals.
Provided,  however, that any refill dispensed prior to the expiration of
the prescribed and approved coverage period pursuant to this  paragraph,
shall,  to  the  extent practicable, be limited in quantity so as not to
exceed the remaining dosage initially approved for  coverage.  Provided,
further,  that  such  limited  refilling  shall  not  limit  or restrict
coverage  with  regard  to  any  previously  or  subsequently   approved
prescription  for  eye drop medication and shall be subject to the terms
and conditions of the policy  otherwise  applicable  to  this  coverage.
Provided,  further,  that  a  pharmacist  may  contact  the  prescribing
physician or health care provider to verify the prescription.
(29) Every individual policy which provides medical, major medical  or
similar   comprehensive-type  coverage  that  includes  coverage  for  a
physical or well care visit once in every three hundred sixty-five  days
shall  be  interpreted to mean that such physical or well care visit can
be had once every calendar year, regardless of whether or not  a  period
of  three hundred sixty-five days has passed since the previous physical
or well care visit.
* (30)(A) Every  policy  that  provides  hospital,  major  medical  or
similar  comprehensive coverage shall provide inpatient coverage for the
diagnosis  and  treatment   of   substance   use   disorder,   including
detoxification  and  rehabilitation  services.  Such  inpatient coverage
shall include unlimited medically necessary treatment for substance  use
disorder  treatment  services provided in residential settings. Further,
such inpatient  coverage  shall  not  apply  financial  requirements  or
treatment  limitations,  including  utilization  review requirements, to
inpatient substance use disorder benefits that are more restrictive than
the predominant financial requirements and treatment limitations applied
to substantially all  medical  and  surgical  benefits  covered  by  the
policy.
(B)   Coverage  provided  under  this  paragraph  may  be  limited  to
facilities in New York state that are licensed, certified  or  otherwise
authorized by the office of alcoholism and substance abuse services and,
in  other  states, to those which are accredited by the joint commission
as  alcoholism,  substance  abuse,  or  chemical  dependence   treatment
programs  and  are similarly licensed, certified or otherwise authorized
in the state in which the facility is located.
(C) Coverage provided under this paragraph may be  subject  to  annual
deductibles and co-insurance as deemed appropriate by the superintendent
and  that  are  consistent with those imposed on other benefits within a
given policy.
(D) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of  alcoholism
and  substance  abuse  services  that are participating in the insurer's

provider network. Coverage provided under this paragraph  shall  not  be
subject  to  preauthorization.  Coverage  provided  under this paragraph
shall also not be subject to concurrent utilization  review  during  the
first  twenty-eight  days  of  the inpatient admission provided that the
facility notifies the insurer of both  the  admission  and  the  initial
treatment  plan  within two business days of the admission. The facility
shall perform daily clinical review of the patient,  including  periodic
consultation  with the insurer at or just prior to the fourteenth day of
treatment to ensure that the facility is using  the  evidence-based  and
peer  reviewed  clinical  review  tool  utilized by the insurer which is
designated by the office of alcoholism and substance abuse services  and
appropriate  to  the  age  of  the patient, to ensure that the inpatient
treatment is medically necessary for the patient.  Prior  to  discharge,
the  facility  shall  provide the patient and the insurer with a written
discharge plan which shall describe arrangements for additional services
needed following discharge from the  inpatient  facility  as  determined
using the evidence-based and peer-reviewed clinical review tool utilized
by  the  insurer  which  is  designated  by the office of alcoholism and
substance  abuse  services.  Prior  to  discharge,  the  facility  shall
indicate  to the insurer whether services included in the discharge plan
are secured or determined to be reasonably  available.  Any  utilization
review  of  treatment  provided  under  this  subparagraph may include a
review  of  all  services  provided  during  such  inpatient  treatment,
including  all  services  provided during the first twenty-eight days of
such inpatient treatment. Provided, however, the insurer shall only deny
coverage for any portion  of  the  initial  twenty-eight  day  inpatient
treatment  on  the basis that such treatment was not medically necessary
if such inpatient treatment was contrary to the evidence-based and  peer
reviewed   clinical  review  tool  utilized  by  the  insurer  which  is
designated by the office of alcoholism and substance abuse services.  An
insured  shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.
(E) An insurer  shall  make  available  to  any  insured,  prospective
insured,  or in-network provider, upon request, the criteria for medical
necessity determinations under the  policy  with  respect  to  inpatient
substance use disorder benefits.
(F) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement;
(iii)  "treatment  limitation"  means  limits  on  the  frequency   of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy; and
(iv)  "substance use disorder" shall have the meaning set forth in the
most recent edition of the diagnostic and statistical manual  of  mental
disorders  or  the  most  recent edition of another generally recognized
independent  standard  of  current  medical  practice,   such   as   the
international classification of diseases.
(G)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
* NB There are 2 par (30)'s
* (30) Every policy  that  provides  medical  coverage  that  includes
coverage for physician services in a physician's office and every policy
that provides major medical or similar comprehensive-type coverage shall
include  coverage  for  equipment and supplies used for the treatment of
ostomies, if prescribed by a physician or  other  licensed  health  care
provider  legally  authorized  to  prescribe  under  title  eight of the
education law. Such coverage shall be subject to annual deductibles  and
coinsurance  as  deemed  appropriate by the superintendent. The coverage
required by this paragraph shall be identical to, and shall not  enhance
or  increase  the coverage required as part of essential health benefits
as defined in subsection (a)  of  section  three  thousand  two  hundred
seventeen-i of this article.
* NB There are 2 par (30)'s
(31)  (A) Every policy that provides medical, major medical or similar
comprehensive-type coverage shall provide outpatient  coverage  for  the
diagnosis   and   treatment   of   substance   use  disorder,  including
detoxification and rehabilitation  services.  Such  coverage  shall  not
apply  financial  requirements  or  treatment  limitations to outpatient
substance use disorder benefits  that  are  more  restrictive  than  the
predominant  financial requirements and treatment limitations applied to
substantially all medical and surgical benefits covered by the policy.
(B) Coverage under this paragraph may be limited to facilities in this
state that are licensed, certified or otherwise authorized by the office
of addiction services and supports to provide outpatient  substance  use
disorder  services and crisis stabilization centers licensed pursuant to
section 36.01 of the mental hygiene law, and, in other states, to  those
which  are  accredited by the joint commission as alcoholism or chemical
dependence  substance  abuse  treatment  programs  and   are   similarly
licensed,  certified,  or otherwise authorized in the state in which the
facility is located.
(C) Coverage provided under this paragraph may be  subject  to  annual
deductibles and co-insurance as deemed appropriate by the superintendent
and  that  are  consistent with those imposed on other benefits within a
given policy.
(D) A policy providing coverage for substance  use  disorder  services
pursuant  to this paragraph shall provide up to twenty outpatient visits
per policy or calendar year to  an  individual  who  identifies  him  or
herself  as  a  family  member  of a person suffering from substance use
disorder and who seeks treatment as a family  member  who  is  otherwise
covered  by  the  applicable  policy  pursuant  to  this  paragraph. The
coverage required by this paragraph shall include treatment as a  family
member  pursuant to such family member's own policy provided such family
member:
(i) does not exceed the allowable number of family visits provided  by
the applicable policy pursuant to this paragraph; and
(ii)  is otherwise entitled to coverage pursuant to this paragraph and
such family member's applicable policy.
(E) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of  alcoholism
and  substance abuse services for the provision of outpatient, intensive
outpatient, outpatient rehabilitation  and  opioid  treatment  that  are
participating in the insurer's provider network. Coverage provided under
this  paragraph  shall  not  be  subject  to  preauthorization. Coverage
provided under this paragraph shall not be subject to concurrent  review
for  the  first  four  weeks  of  continuous  treatment,  not  to exceed
twenty-eight visits, provided the facility notifies the insurer of  both
the  start  of  treatment  and  the  initial  treatment  plan within two
business days. The facility shall perform  clinical  assessment  of  the
patient  at each visit, including periodic consultation with the insurer
at or just prior to the fourteenth day of treatment to ensure  that  the
facility  is  using the evidence-based and peer reviewed clinical review
tool utilized by the insurer  which  is  designated  by  the  office  of
alcoholism  and  substance  abuse services and appropriate to the age of
the patient, to  ensure  that  the  outpatient  treatment  is  medically
necessary  for  the  patient.  Any  utilization  review of the treatment
provided under this subparagraph may include a review  of  all  services
provided  during  such  outpatient  treatment,  including  all  services
provided during the first four weeks of  continuous  treatment,  not  to
exceed  twenty-eight  visits,  of  such  outpatient treatment. Provided,
however, the insurer shall only deny coverage for  any  portion  of  the
initial  four  weeks of continuous treatment, not to exceed twenty-eight
visits, for outpatient treatment on the basis that  such  treatment  was
not medically necessary if such outpatient treatment was contrary to the
evidence-based  and  peer  reviewed clinical review tool utilized by the
insurer which is designated by the office of  alcoholism  and  substance
abuse  services.  An  insured shall not have any financial obligation to
the facility for any treatment under this subparagraph  other  than  any
copayment,  coinsurance,  or  deductible  otherwise  required  under the
policy.
(F) The criteria for medical necessity determinations under the policy
with respect to outpatient substance use disorder benefits shall be made
available by  the  insurer  to  any  insured,  prospective  insured,  or
in-network provider upon request.
(G) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement;
(iii)  "treatment  limitation"  means  limits  on  the  frequency   of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy; and
(iv)  "substance use disorder" shall have the meaning set forth in the
most recent edition of the diagnostic and statistical manual  of  mental

disorders  or  the  most  recent edition of another generally recognized
independent  standard  of  current  medical   practice   such   as   the
international classification of diseases.
(H)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
(I) This subparagraph shall apply to crisis stabilization  centers  in
this  state  that  are  licensed pursuant to section 36.01 of the mental
hygiene law and participate in the insurer's provider network.  Benefits
for  care  in  a  crisis  stabilization  center  shall not be subject to
preauthorization. All treatment provided under this subparagraph may  be
reviewed  retrospectively.  Where  care  is  denied  retrospectively, an
insured shall not have any financial obligation to the facility for  any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.
* (J)  This  subparagraph shall apply to facilities in this state that
are licensed, certified,  or  otherwise  authorized  by  the  office  of
addiction  services  and  supports  for  the  provision  of  outpatient,
intensive outpatient, outpatient  rehabilitation  and  opioid  treatment
that  are participating in the insurer's provider network. Reimbursement
for covered outpatient treatment provided by such facilities shall be at
rates negotiated between the insurer  and  the  participating  facility,
provided  that such rates are not less than the rates that would be paid
for such treatment pursuant to  the  medical  assistance  program  under
title  eleven  of  article  five  of  the  social  services law. For the
purposes of this subparagraph, the rates that would  be  paid  for  such
treatment  pursuant to the medical assistance program under title eleven
of article five of the social services law shall be the  rates  with  an
effective  date  of  April  first  of the preceding year, which shall be
established prior to October first of the preceding calendar year. Prior
to  the  submission  of  premium  rate  filings  and  applications,  the
superintendent  shall  provide  insurers  with  guidance  on  factors to
consider in calculating the impact of rate changes for the  purposes  of
submitting  premium  rate filings and applications to the superintendent
for the subsequent policy year. To the extent that  the  rates  with  an
effective   date   of  April  first  differ  from  the  estimated  rates
incorporated in premium rate  filings  and  applications,  insurers  may
account  for  such  differences  in  future  premium  rate  filings  and
applications submitted to the superintendent for approval.
* NB Effective January 1, 2025
(31-a) (A) No policy that provides medical, major medical  or  similar
comprehensive-type coverage and provides coverage for prescription drugs
for  medication  for  the  treatment  of  a substance use disorder shall
require prior authorization for an initial or renewal  prescription  for
the detoxification or maintenance treatment of a substance use disorder,
including  all buprenorphine products, methadone, long acting injectable
naltrexone, or medication for opioid  overdose  reversal  prescribed  or
dispensed to an insured covered under the policy, including federal food
and   drug   administration-approved  over-the-counter  opioid  overdose
reversal medication as prescribed, dispensed or as otherwise  authorized
under state or federal law, except where otherwise prohibited by law.
(B)   Coverage  provided  under  this  paragraph  may  be  subject  to
copayments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the policy.
(31-b) Every policy that provides coverage for treatment at an  opioid
treatment program shall not impose a co-payment fee during the course of
treatment  on  any  insured for such treatment. For the purposes of this

section "opioid treatment  program"  means  a  program  or  practitioner
engaged  in  opioid  treatment  of  individuals  with  an opioid agonist
treatment medication.
(32)  No  policy  delivered  or issued for delivery in this state that
provides  reimbursement  for  non-physician  surgical  first   assistant
services  when  the  services  are  provided by a non-physician surgical
first assistant shall exclude  such  coverage  on  the  basis  that  the
non-physician  surgical  first  assistant  services  were performed by a
registered nurse first assistant provided that: (A) the registered nurse
first assistant is certified in operating room nursing; (B) the services
are within the scope of  practice  of  a  non-physician  surgical  first
assistant;  and  (C)  the  terms  and conditions of the policy otherwise
provide for the coverage of the  services.  Nothing  in  this  paragraph
shall  be  construed  to  prevent  the medical management or utilization
review of the services or prevent a policy from requiring that  services
are to be provided through a network of participating providers who meet
certain    requirements    for    participation,    including   provider
credentialing.
* (33) Every policy delivered or issued for  delivery  in  this  state
that  provides  coverage  for  prescription drugs subject to a copayment
shall charge a copayment for a limited initial prescription of an opioid
drug,  which  is  prescribed  in  accordance  with  paragraph   (b)   of
subdivision  five  of  section  thirty-three  hundred  one of the public
health law, that is either (i) proportional between the copayment for  a
thirty-day supply and the amount of drugs the patient was prescribed; or
(ii)  equivalent  to  the  copayment for a full thirty-day supply of the
opioid drug, provided that no additional copayments may be  charged  for
any additional prescriptions for the remainder of the thirty-day supply.
* NB There are 2 par (33)'s
* (33)  Whenever  in  this  section  an insurer is required to provide
benefits with no coinsurance or deductible, the requirement only applies
with respect to participating providers in  the  insurer's  network,  or
with  respect  to  non-participating  providers, if the insurer does not
have a participating provider in the in-network benefits portion of  its
network  with  the  appropriate  training  and  experience  to  meet the
particular health care needs of the insured pursuant to  subsection  (d)
of section three thousand two hundred seventeen-d of this article.
* NB There are 2 par (33)'s
(34)  Health  care forensic examinations performed pursuant to section
twenty-eight hundred five-i of the public health law covered  under  the
policy shall not be subject to annual deductibles or coinsurance.
(35)  (A)  Every policy delivered or issued for delivery in this state
that provides coverage for  inpatient  hospital  care  or  coverage  for
physician   services  shall  provide  coverage  for  the  diagnosis  and
treatment of mental health conditions as follows:
* (i) where the policy provides coverage for inpatient hospital  care,
such  policy  shall include 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
* NB Effective until January 1, 2025 and shall remain in effect  until
after  the  superintendent of financial services and the commissioner of
health have promulgated regulations
*(i) where the policy provides coverage for inpatient  hospital  care,
such  policy shall include benefits for: inpatient care in a hospital as
defined by subdivision ten of section 1.03 of the  mental  hygiene  law;
sub-acute  care  in  a  residential facility licensed or operated by the
office  of  mental health; outpatient care provided by 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 by
a facility operated by the office  of  mental  health;  outpatient  care
provided  by  a crisis stabilization center licensed pursuant to section
36.01 of the mental hygiene law; outpatient care provided  by  a  mobile
crisis intervention services provider licensed, certified, or designated
by  the  office of mental health or the office of addiction services and
supports; outpatient and inpatient care for critical  time  intervention
services  and outpatient care for assertive community treatment services
provided  by  facilities  issued  an  operating   certificate   by   the
commissioner  of  mental  health  pursuant  to the provisions of article
thirty-one of the mental hygiene law, beginning  no  later  than  thirty
days  following  discharge from a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law or the emergency department of
a hospital licensed pursuant  to  article  twenty-eight  of  the  public
health law; or, for care provided in other states, to similarly licensed
or certified hospitals, facilities, or licensed, certified or designated
providers; and
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
(ii)  where  the policy provides coverage for physician services, such
policy  shall  include  benefits  for  outpatient  care  provided  by  a
psychiatrist  or  psychologist  licensed  to  practice  in this state, 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,  a  mental  health  counselor,  marriage  and  family
therapist,  or  psychoanalyst  licensed  pursuant to article one hundred
sixty-three of the education  law,  a  nurse  practitioner  licensed  to
practice  in  this  state,  or  a professional corporation or university
faculty practice corporation thereof. Nothing herein shall be  construed
to  modify or expand the scope of practice of a mental health counselor,
marriage and family therapist, or  psychoanalyst  licensed  pursuant  to
article  one  hundred sixty-three of the education law. Further, nothing
herein shall be construed to create a new mandated health benefit.
(B) Coverage required by this  paragraph  may  be  subject  to  annual
deductibles,  copayments and coinsurance as may be deemed appropriate by
the superintendent and shall be consistent with those imposed  on  other
benefits under the policy.
(C)   Coverage   under   this  paragraph  shall  not  apply  financial
requirements or treatment limitations to mental health benefits that are
more  restrictive  than  the  predominant  financial  requirements   and
treatment  limitations applied to substantially all medical and surgical
benefits covered by the policy.
(D) The criteria for medical necessity determinations under the policy
with respect to mental health benefits shall be made  available  by  the
insurer to any insured, prospective insured, or in-network provider upon
request.
(E) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement;
* (iii)  "treatment  limitation"  means  limits  on  the  frequency of
treatment, number of visits, days of coverage, or other  similar  limits
on  the  scope  or  duration  of  treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting  or
excluding  benefits  based on medical necessity, or based on whether the
treatment is  experimental  or  investigational;  formulary  design  for
prescription   drugs;   network  tier  design;  standards  for  provider
admission to participate in a network,  including  reimbursement  rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first or step therapy protocols; exclusions  based  on  failure  to
complete  a  course  of  treatment; and restrictions based on geographic
location, facility type, provider specialty,  and  other  criteria  that
limit  the scope or duration of benefits for services provided under the
policy; and
* NB Effective until January 1, 2025 and shall remain in effect  until
after  the  superintendent of financial services and the commissioner of
health have promulgated regulations
* (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;
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (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.
* NB  Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the  commissioner  of
health have promulgated regulations
* (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;
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (v)  "assertive  community treatment services" means a comprehensive
and  integrated   combination   of   treatment,   rehabilitation,   case
management,  and  support  services  primarily  provided in an insured's
residence or other community locations  by  a  mobile  multidisciplinary

mental  health treatment team licensed pursuant to article thirty-one of
the mental hygiene law;
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (vi)  "critical  time intervention services" means services rendered
by a provider licensed under article thirty-one of  the  mental  hygiene
law that provides evidence-based, therapeutic interventions that include
intensive  outreach, engagement, and care coordination services that are
provided to an insured before the insured is discharged  from  inpatient
care  in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law or the emergency department of  a  hospital  licensed
pursuant  to  article twenty-eight of the public health law and continue
after discharge until the insured is stabilized; and
* NB Effective January 1, 2025 but shall not take effect  until  after
the  superintendent of financial services and the commissioner of health
have promulgated regulations
* (vii) "residential facility" means crisis residence  facilities  and
community  residences  for eating disorder integrated treatment programs
licensed pursuant to article thirty-one of the mental hygiene law.
* NB Effective January 1, 2025 but shall not take effect  until  after
the  superintendent of financial services and the commissioner of health
have promulgated regulations
(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 and crisis residence
facilities in this state that are licensed or operated 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 and benefits for sub-acute
care in a crisis residence facility licensed or operated by  the  office
of  mental  health  shall  not  be subject to preauthorization. Coverage
provided under this subparagraph shall also not be subject to concurrent
utilization review for individuals who have  not  attained  the  age  of
eighteen  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  insured, 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 insured, to ensure that the  inpatient
care  is  medically  necessary for the insured. For individuals who have
attained age eighteen, coverage provided under this  subparagraph  shall
also not be subject to concurrent review during the first thirty days of
the  inpatient  or residential 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 insured, 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 insured, to  ensure  that  the  inpatient  or  residential  care  is
medically  necessary  for the insured. However, concurrent review may be
performed during the first thirty days  if  an  insured  meets  clinical

criteria  designated by the office of mental health or where the insured
is admitted to a hospital or facility which has been designated  by  the
office  of mental health for concurrent review, in consultation with the
commissioner  of  health  and the superintendent. 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  by  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.
* (I)  This  subparagraph  shall  apply  to mobile crisis intervention
services providers licensed, certified, or designated by the  office  of
mental  health  or  the  office  of addiction services and supports. For
purposes of this subparagraph,  "mobile  crisis  intervention  services"
means  mental  health and substance use disorder services consisting of:
(1) telephonic crisis triage and response; (2) mobile crisis response to
provide intervention and facilitate access to  other  behavioral  health
services;  and  (3)  mobile  and telephonic follow-up services after the
initial crisis response until the insured is stabilized, provided to  an
insured  who  is experiencing, or is at imminent risk of experiencing, a
behavioral health crisis, which includes instances in which  an  insured
cannot  manage  their  primarily  psychiatric  or  substance use related
symptoms  without   de-escalation   or   intervention.   Mobile   crisis
intervention  services  do  not  include services provided to an insured
after the insured has been stabilized.
(i)  Benefits  for  covered  services  provided  by  a  mobile  crisis
intervention services provider shall not be subject to preauthorization.
Except  where  otherwise  required  by law, nothing in this subparagraph
shall prevent services provided subsequent to the  provision  of  mobile
crisis intervention services from being subject to preauthorization.
(ii)  Benefits  for  covered  services  provided  by  a  mobile crisis
intervention services provider shall be covered  regardless  of  whether
the  mobile  crisis  intervention  services  provider is a participating
provider.
(iii) If the covered services  are  provided  by  a  non-participating
mobile  crisis  intervention  services  provider,  an  insurer shall not
impose any administrative requirement or limitation on coverage that  is
more  restrictive  than  the  requirements  or limitations that apply to
covered  services  received   from   a   participating   mobile   crisis
intervention services provider.
(iv)  If  the  covered  services  are  provided by a non-participating
mobile crisis intervention services provider, the  insured's  copayment,
coinsurance,  and  deductible  shall  be the same as would apply if such
covered  services  were  provided  by  a  participating  mobile   crisis
intervention services provider.
(v) A mobile crisis intervention services provider 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 subparagraph, except for the collection of  in-network  copayments,

coinsurance,  or  deductibles  for  which the insured is responsible for
under the terms of the policy.
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
(J)  This  subparagraph  shall  apply  to  school-based  mental health
clinics that are licensed pursuant to article thirty-one of  the  mental
hygiene  law  and  provide outpatient care in pre-school, elementary, or
secondary schools. An insurer shall provide  reimbursement  for  covered
outpatient care when provided by such school-based mental health clinics
at  a pre-school, elementary, or secondary school, regardless of whether
the school-based mental health clinic  furnishing  such  services  is  a
participating  provider with respect to such services. Reimbursement for
such covered services shall  be  at  the  rate  negotiated  between  the
insurer  and  school-based  mental health clinic or, in the absence of a
negotiated rate, an amount no less than the rate that would be paid  for
such  services  pursuant  to  the medical assistance program under title
eleven of article five of the social services law. Payment by an insurer
pursuant to this section shall be  payment  in  full  for  the  services
provided.  The  school-based mental health clinic 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 subparagraph, except for the collection of  in-network  copayments,
coinsurance,  or  deductibles  for  which the insured is responsible for
under the terms of the policy.
* (K) This subparagraph shall apply to outpatient  treatment  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, that is participating in the  insurer's
provider   network.   Reimbursement  for  covered  outpatient  treatment
provided by such a facility shall be at  rates  negotiated  between  the
insurer and the participating facility, provided that such rates are not
less  than  the  rates that would be paid for such treatment pursuant to
the medical assistance program under title eleven of article five of the
social services law. For the purposes of this  subparagraph,  the  rates
that would be paid for such treatment pursuant to the medical assistance
program  under  title  eleven of article five of the social services law
shall be the rates  with  an  effective  date  of  April  first  of  the
preceding year, which shall be established prior to October first of the
preceding calendar year. Prior to the submission of premium rate filings
and   applications,  the  superintendent  shall  provide  insurers  with
guidance on factors to  consider  in  calculating  the  impact  of  rate
changes  for  the  purposes  of  submitting  premium  rate  filings  and
applications to the superintendent for the subsequent  policy  year.  To
the  extent  that the rates with an effective date of April first differ
from the estimated  rates  incorporated  in  premium  rate  filings  and
applications,  insurers  may  account  for  such  differences  in future
premium rate filings and applications submitted  to  the  superintendent
for approval.
* NB Effective January 1, 2025
* (36)  (A) Every policy which provides hospital, surgical, or medical
coverage and which offers maternity coverage pursuant to  paragraph  ten
of this subsection shall also provide coverage for abortion services for
an enrollee.
(B)  Coverage  for abortion shall not be subject to annual deductibles
or coinsurance, including co-payments,  unless  the  policy  is  a  high

deductible  health  plan as defined in section 223(c)(2) of the internal
revenue code of 1986, in which case coverage for abortion may be subject
to the plan's annual deductible.
(C)   Coverage  for  abortion  shall  include  coverage  of  any  drug
prescribed for the purpose of an abortion, including  both  generic  and
brand  name  drugs,  even if such drug has not been approved by the food
and drug administration for abortion, provided, however, that such  drug
shall  be  a  recognized medication for abortion in one of the following
established reference compendia:
(i) The WHO Model Lists of Essential Medicines;
(ii) The WHO Abortion Care Guidance; or
(iii) The National Academies of  Science,  Engineering,  and  Medicine
Consensus Study Report.
* NB There are 2 par (36)'s
* (36)(A)  Every  policy that includes coverage for dialysis treatment
that requires such services to be provided by an in-network provider and
that does not provide coverage  for  out-of-network  dialysis  treatment
shall  not  deny  coverage  of  such  services  because the services are
provided by an  out-of-network  provider,  provided  that  each  of  the
following conditions are met:
(i)  The  out-of-network  provider  is  duly  licensed to practice and
authorized to provide such treatment;
(ii) The out-of-network provider is located outside the  service  area
of the insurer;
(iii)  The in-network healthcare provider treating the insured for the
condition issues a written order for dialysis treatment stating that  in
his or her opinion such treatment is necessary;
(iv) The insured has notified, in writing, the insurer at least thirty
days  in  advance  of  the proposed date or dates of such out-of-network
dialysis treatment. The notice shall include the authorization  required
by  clause  (iii)  of  this  subparagraph. In the event the insured must
travel on sudden notice due to family or other emergency, shorter notice
may be permitted, provided that the insurer has  reasonable  opportunity
to review the travel and treatment plans of the insured;
(v)  The  insurer  shall  have  the  right to pre-approve the dialysis
treatment and schedule; and
(vi) Such coverage is limited to no greater  than  ten  out-of-network
treatments in a calendar year.
(B)  Where  coverage for out-of-network dialysis treatment is provided
pursuant to subparagraph (A) of this  paragraph,  no  insurer  shall  be
obligated  to reimburse the out-of-network provider at an amount greater
than it would have  paid  for  the  same  treatment  within  a  network,
including  all  drugs and ancillary services tied to dialysis treatment,
and any amount charged by a provider in excess of the amount  reimbursed
by  the insurer shall be the responsibility of the insured receiving the
out-of-network services.
(C) Such coverage of  out-of-network  dialysis  services  required  by
subparagraph  (A)  of  this  paragraph shall otherwise be subject to the
limitations, exclusions and terms of  the  policy,  including,  but  not
limited  to,  utilization  review,  annual  deductibles, copayments, and
coinsurance, consistent with those required for other  similar  benefits
under the policy.
* NB There are 2 par (36)'s
* (37)  Any policy that provides coverage for prescription drugs shall
apply any third-party payments, financial assistance, discount,  voucher
or  other  price reduction instrument for out-of-pocket expenses made on
behalf of an insured individual for the cost of a prescription  drug  to
the insured's deductible, copayment, coinsurance, out-of-pocket maximum,

or  any  other  cost-sharing  requirement  when calculating such insured
individual's overall contribution to any out-of-pocket  maximum  or  any
cost-sharing  requirement.  If  under  federal  law, application of this
requirement  would  result in health savings account ineligibility under
26  USC  223,  this  requirement  shall   apply   for   health   savings
account-qualified  high  deductible  health  plans  with  respect to the
deductible of such a plan after the enrollee has satisfied  the  minimum
deductible  under  26  USC  223,  except  for  with  respect to items or
services that are preventive care pursuant to 26  USC  223(c)(2)(C),  in
which  case the requirements of this paragraph shall apply regardless of
whether the minimum deductible under 26 USC 223 has been satisfied. This
paragraph only applies to a prescription  drug  that  is  either  (A)  a
brand-name drug without an AB rated generic equivalent, as determined by
the United States Food and Drug Administration; or (B) a brand-name drug
with  an AB rated generic equivalent, as determined by the United States
Food and  Drug  Administration,  and  the  insured  has  access  to  the
brand-name  drug  through  prior authorization by the insurer or through
the insurer's appeal process, including any step-therapy process; or (C)
a  generic  drug  the  insurer  will  cover,  with  or   without   prior
authorization or an appeal process.
* NB There are 2 par (37)'s
* (37) (A) Definitions. For the purpose of this paragraph:
(i) "Same reimbursement amount" shall mean that any coverage described
under  subparagraph  (B)  of  this  paragraph  shall  provide  the  same
benchmark index, including the same  average  wholesale  price,  maximum
allowable  cost  and  national  prescription drug codes to reimburse all
pharmacies participating in the insurance network regardless of  whether
a pharmacy is a mail order pharmacy or a non-mail order pharmacy.
(ii)  "Mail order pharmacy" means a pharmacy whose primary business is
to  receive  prescriptions  by  mail,  telefax  or  through   electronic
submissions  and  to  dispense medication to patients through the use of
the United States mail or other common or contract carrier services  and
provides  any  consultation  with  patients  electronically  rather than
face-to-face.
(B) Any policy that provides coverage  for  prescription  drugs  shall
permit  each  insured  to  fill  any  covered  prescription  that may be
obtained at a network  participating  mail  order  or  other  non-retail
pharmacy,  at  the insured's option, at a network participating non-mail
order retail pharmacy provided that the network  participating  non-mail
order  retail  pharmacy agrees to the same reimbursement amount that the
insurer has established for the  network  participating  mail  order  or
other non-retail pharmacy. In such a case, the policy shall not impose a
co-payment  fee or other condition on any insured who elects to purchase
prescription drugs from a network participating  non-mail  order  retail
pharmacy  which  is  not  also  imposed on insureds electing to purchase
drugs from a  network  participating  mail  order  or  other  non-retail
pharmacy;  provided,  however,  that the provisions of this subparagraph
shall not supersede the terms of a collective  bargaining  agreement  or
apply  to a policy that is a result of a collective bargaining agreement
between an employer and a recognized or certified employee organization.
* NB There are 2 par (37)'s
(38) Every policy that provides coverage  for  hospital,  surgical  or
medical  care shall provide the following coverage for pasteurized donor
human milk (PDHM), which may include fortifiers as medically  indicated,
for  inpatient use, for which a licensed medical practitioner has issued
an order for an infant who is medically or physically unable to  receive
maternal breast milk or participate in breast feeding or whose mother is
medically or physically unable to produce maternal breast milk at all or

in  sufficient  quantities  or  participate  in  breast  feeding despite
optimal lactation support. Such infant  shall:  (i)  have  a  documented
birth  weight of less than one thousand five hundred grams; or (ii) have
a congenital or acquired condition that places the infant at a high risk
for development of necrotizing enterocolitis.
(j)  (1)  Every  insurer  issuing  a  policy  of  accident  and health
insurance for  delivery  in  this  state  which  provides  coverage  for
in-patient  hospital  care  must make available and, if requested by the
policyholder, provide coverage for care in a nursing home. Such coverage
shall be made available at the inception of all new policies  and,  with
respect  to  all  other  policies  at any anniversary date of the policy
subject to evidence of insurability.
(A) In this paragraph nursing home care means the continued  care  and
treatment  of  a covered person who is under the care of a physician but
only if (i) the care is provided in a nursing home as defined in section
twenty-eight hundred one of the public health law or a  skilled  nursing
facility  as  defined in subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq, (ii) the covered person  has  been  in  a
hospital  for  at  least three days immediately preceding admission, and
(iii)  further  hospitalization  would  otherwise  be   necessary.   The
aggregate  of  the  number of covered days of care in a hospital and the
number of covered days of care in a nursing home, with two days of  care
in  a  nursing home equivalent to one day of care in a hospital, may not
exceed the number of covered days of hospital care  provided  under  the
contract  in  a benefit period. The level of benefits to be provided for
nursing home care must be reasonably related to  the  benefits  provided
for hospital care.
(B)  Ambulatory care means care in hospital out-patient facilities, as
a hospital is defined in section twenty-eight hundred one of the  public
health  law  or  subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq,  and  physicians'  offices.  Ambulatory  care  in
hospital  out-patient  facilities  means services for diagnostic X-rays,
laboratory and pathological examinations, physical therapy and radiation
therapy, and services and medications used  for  nonexperimental  cancer
chemotherapy and cancer hormone therapy, provided that such services and
medications  are  (i)  related  to  and  necessary  for the treatment or
diagnosis of  the  patient's  illness  or  injury,  (ii)  ordered  by  a
physician  and (iii) in the case of physical therapy, services are to be
furnished in connection with the same illness for which the patient  had
been  hospitalized  or in connection with surgical care, but in no event
need benefits be provided for physical therapy which commences more than
six months after discharge from a hospital or the date surgical care was
rendered, and in no event need benefits for physical therapy be provided
after three hundred sixty-five days from the date of  discharge  from  a
hospital  or  the  date  surgical  care was rendered. Ambulatory care in
physicians' offices means  services  for  diagnostic  X-rays,  radiation
therapy,  laboratory  and  pathological  examinations,  and services and
medications used for  nonexperimental  cancer  chemotherapy  and  cancer
hormone therapy, provided that such services and medications are related
to and necessary for the treatment or diagnosis of the patient's illness
or  injury,  and  ordered  by  a  physician. Such coverage shall be made
available at the inception of all new policies and, with respect to  all
other  policies,  at  any  anniversary  date  of  the  policy subject to
evidence of insurability.
(2) Every insurer issuing a policy of accident  and  health  insurance
for  delivery in this state which provides coverage supplementing part A
and part B of subchapter XVIII of the federal Social  Security  Act,  42
U.S.C.    §§  1395  et seq, must make available and, if requested by the

insured, provide coverage of supplemental home care visits beyond  those
provided  by  part  A  and  part  B,  sufficient to produce an aggregate
coverage of three hundred sixty-five home case visits per  policy  year.
Such  coverage  shall  be provided pursuant to regulations prescribed by
the superintendent.
(3) Consistent with federal law, every insurer  issuing  a  policy  of
accident  and health insurance for delivery in this state which provides
coverage supplementing part A and part B  of  subchapter  XVIII  of  the
federal  Social  Security  Act,  42  USC  §§  1395  et  seq., shall make
available and, if requested by the  insured,  provide  coverage  for  at
least  ninety  days  of  care  in  a  nursing home as defined in section
twenty-eight hundred one of the public health  law,  except  where  such
coverage   would   duplicate   coverage  that  is  available  under  the
aforementioned subchapter XVIII. Such coverage shall be  made  available
at  the  inception  of  all  new policies and, with respect to all other
policies, at each anniversary date of the policy.
(A) Coverage shall be subject to a copayment  of  twenty-five  dollars
per day.
(B)  Brochures  describing  such  coverage  must  be  provided  to all
applicants  at  the  time  of  application  for  all  new  policies  and
thereafter  on  each anniversary date of the policy, and with respect to
all other policies annually at each anniversary date of the policy. Such
brochures must be approved by the superintendent  in  consultation  with
the commissioner of health.
(C)  The  commensurate  rate  for the coverage must be approved by the
superintendent.
(D) Such insurers shall report to the  superintendent  each  year  the
number  of  contract  holders  to  whom  such  insurers have issued such
policies for nursing home coverage and the approximate number of persons
covered by such policies.
(k) Any person, partnership or  corporation  willfully  violating  any
provision  of  this  section,  regulation or order of the superintendent
made in accordance with this section, shall forfeit to the people of the
state a sum not to exceed one hundred dollars for each  such  violation.
The  superintendent may also suspend or revoke the license of an insurer
or agent or broker for any such willful violation.
(l) An  insurer  shall  not  offer  individual  hospital,  medical  or
surgical  expense  insurance  policies  unless  the  policies  meet  the
requirements of subsection (b) of section four  thousand  three  hundred
twenty-eight  of this chapter. Such policies that are offered within the
health benefit exchange established by this state also  shall  meet  any
requirements established by the health benefit exchange.
(m)  An  insurer  shall  not be required to offer the policyholder any
benefits that must be made available pursuant to  this  section  if  the
benefits  must  be  covered as essential health benefits. For any policy
issued within the health benefit exchange established by this state,  an
insurer  shall  not  be  required to offer the policyholder any benefits
that must be made available pursuant to this section.  For  purposes  of
this  subsection, "essential health benefits" shall have the meaning set
forth  in  subsection  (a)  of  section  three  thousand   two   hundred
seventeen-i of this article.