2023 New York Laws › ISC - Insurance › Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations › 4303 - Benefits.

§  4303.  Benefits.  (a)  Every  contract issued by a hospital service
corporation or health service corporation which  provides  coverage  for
in-patient hospital care shall also provide coverage:
(1) For preadmission testing performed in hospital facilities prior to
scheduled  surgery.  A  patient who uses the out-patient facilities of a
hospital shall be entitled to benefits for tests ordered by a  physician
which are performed as a planned preliminary to admission of the patient
as an in-patient for surgery in the same hospital, provided that:
(A)  tests  are  necessary  for  and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed,
(B) reservations for a hospital bed and for an  operating  room  shall
have been made prior to the performance of the tests,
(C) surgery actually takes place within seven days of such presurgical
tests, and
(D) the patient is physically present at the hospital for the tests.
(2)  (A)  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  contract  subject  to   this
paragraph.
(C)  For  the purpose of this provision, "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 the purpose of this  provision,  "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  the  purpose  of  this provision, "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 subscriber from a
facility or to deliver a newborn child (including the placenta).
(3)  For home care to residents in this state. Such home care coverage
shall be included at the  inception  of  all  new  contracts  and,  with
respect  to  all  other  contracts, added at any anniversary date of the
contract subject to evidence  of  insurability.  Such  coverage  may  be
subject  to an annual deductible of not more than fifty dollars for each
covered person and may be  subject  to  a  coinsurance  provision  which
provides  for  coverage  of  not  less  than seventy-five percent of the
reasonable cost of services for which  payment  may  be  made.  No  such
corporation need provide such coverage to persons eligible for medicare.
(A)  Home  care  shall mean the care and treatment of a covered person
who is under the care of a physician but only if:
(i) hospitalization or confinement in a nursing facility as defined in
subchapter XVIII of the Social Security Act, 42 U.S.C. §  1395  et  seq,
would otherwise have been required if home care was not provided, and
(ii)  the  plan  covering  the  home health service is established and
approved in writing by such physician.
(B) 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.
(C) Home care 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, and
(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  or provided under the contract if the
covered person had been hospitalized or confined in  a  skilled  nursing
facility  as  defined in subchapter XVIII of the Social Security Act, 42
U.S.C. § 1395 et seq.
(D) 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 covered person. Four hours of home health
aide service shall be considered as one home care visit. Every  contract
issued  by  a hospital service corporation or health service corporation
which provides coverage supplementing part A and part  B  of  subchapter
XVIII  of  the  Social  Security Act, 42 U.S.C. § 1395 et seq, must make
available and, if requested by a subscriber  holding  a  direct  payment
contract  or  by  all  subscribers in a group remittance group or by the
contract holder in the  case  of  group  contracts  issued  pursuant  to
section  four  thousand  three  hundred  five  of  this article, provide
coverage of supplemental home care visits beyond those provided by  part
A  and  part  B,  sufficient  to  produce an aggregate coverage of three
hundred sixty-five home care visits per  contract  year.  Such  coverage
shall   be   provided   pursuant   to   regulations  prescribed  by  the
superintendent. Written notice of  the  availability  of  such  coverage
shall be delivered to the group remitting agent or group contract holder
prior to inception of such contract and annually thereafter, except that

this  notice  shall not be required where a policy covers two hundred or
more employees or  where  the  benefit  structure  was  the  subject  of
collective  bargaining  affecting  persons who are employed in more than
one state.
The provisions of this subsection shall not apply to a contract issued
pursuant  to  section  four  thousand three hundred five of this article
which covers persons employed in more than  one  state  or  the  benefit
structure  of  which  was the subject of collective bargaining affecting
persons who are employed in more than one state.
(b) Every contract issued by a medical expense  indemnity  corporation
or  a  health service corporation which provides coverage for in-patient
surgical care shall include coverage for a second surgical opinion by  a
qualified  physician on the need for surgery, except that this provision
shall not apply to a contract issued pursuant to section  four  thousand
three hundred five of this article which covers persons employed in more
than  one  state  or  the  benefit structure of which was the subject of
collective bargaining affecting persons who are employed  in  more  than
one state.
(c)  (1)  (A)  Every  contract  issued by a corporation subject to the
provisions of this article  which  provides  hospital  service,  medical
expense  indemnity  or  both  shall  provide coverage for maternity care
including hospital, surgical or medical care to  the  same  extent  that
hospital  service,  medical  expense  indemnity or both are provided for
illness or disease under the contract.  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 following 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.
(B) Maternity care coverage also shall  include,  at  minimum,  parent
education,  assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.
(C) The mother shall have the option to be discharged earlier than the
time periods established in subparagraph (A) of this paragraph. 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 contract. The contract
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
contract and subject to  the  provisions  of  this  paragraph,  and  not
subject to deductibles, coinsurance or copayments.
(2)  Coverage  provided  under  this subsection 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.
(d) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and, if requested by  a  person  holding  a  direct  payment  individual
contract or by all persons holding individual contracts in a group whose

premiums  are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand  three
hundred  five  of  this  article,  provide  coverage for care in nursing
homes. Such coverage shall be made available at the inception of all new
contracts  and,  with respect to all other contracts, at any anniversary
date  subject  to  evidence  of  insurability.  Written  notice  of  the
availability  of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such  contract  and
annually thereafter, except that this notice shall not be required where
a  policy  covers  two  hundred  or  more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(2) For the purpose of this subsection, care in  nursing  homes  shall
mean  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 two thousand eight hundred one of the
public health law or a skilled nursing facility as defined in subchapter
XVIII  of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii)
the covered person has been in  a  hospital  for  at  least  three  days
immediately  preceding  admittance  to  the  nursing home or the skilled
nursing facility, and (iii) further hospitalization would  otherwise  be
necessary.  The  aggregate  of  the  number of covered days of care in a
hospital and the number of covered days of care in a nursing home,  with
two  days  of  care in a nursing home equivalent to one day of care in a
hospital, need not exceed the number of covered days  of  hospital  care
provided  under  the contract in a benefit period. The level of benefits
to be provided for nursing home care must be reasonably related  to  the
benefits provided for hospital care.
(e) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and,  if  requested  by  a  person  holding  a direct payment individual
contract or by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in  the
case  of a group contract issued pursuant to section four thousand three
hundred five of this article, provide coverage for  ambulatory  care  in
hospital out-patient facilities, as a hospital is defined in section two
thousand eight hundred one of the public health law, or subchapter XVIII
of  the  Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of
the availability of such  coverage  shall  be  delivered  to  the  group
remitting  agent  or  group  contract  holder prior to inception of such
contract and annually thereafter, except that this notice shall  not  be
required  where  a  policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
(2) For the purpose of this subsection, ambulatory  care  in  hospital
out-patient  facilities  shall  mean  services  for  diagnostic  x-rays,
laboratory and  pathological  examinations,  physical  and  occupational
therapy  and  radiation  therapy,  and services and medications used for
nonexperimental cancer chemotherapy and cancer hormone therapy, provided
that such services and medications are (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 for physical therapy be provided
which commences more than six months after discharge from a hospital  or
the  date  surgical care was rendered, and in no event need benefits for
physical therapy be provided after three hundred  sixty-five  days  from

the  date  of  discharge  from  a hospital or the date surgical care was
rendered. Such coverage shall be made available at the inception of  all
new  contracts  and,  with  respect  to  all  other  contracts,  at  any
anniversary date subject to evidence of insurability.
(f)  (1)  A  medical expense indemnity corporation or a health service
corporation which provides coverage for physicians' services  must  make
available  and,  if  requested  by a person holding an individual direct
payment contract or by all persons holding  individual  contracts  in  a
group  whose  premiums  are paid by a remitting agent or by the contract
holder in the case of a group contract issued pursuant to  section  four
thousand  three  hundred  five  of  this  article,  provide coverage for
ambulatory  care  in  physicians'  offices.  Written   notice   of   the
availability  of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such  contract  and
annually thereafter, except that this notice shall not be required where
a  policy  covers  two  hundred  or  more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(2) For the purpose of this subsection, ambulatory care in physicians'
offices shall mean 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  (i)  related  to  and
necessary  for  the  treatment  or diagnosis of the patient's illness or
injury, and (ii) ordered by a physician. Such  coverage  shall  be  made
available at the inception of all new contracts and, with respect to all
other   contracts  at  any  anniversary  date  subject  to  evidence  of
insurability.
(g)  A  medical  expense  indemnity  corporation,   hospital   service
corporation  or a health service corporation, that provides group, group
remittance or school blanket coverage for  inpatient  hospital  care  or
coverage  for  physician  services shall provide as part of its contract
coverage for the diagnosis and treatment  of  mental  health  conditions
and:
* (1)  where  the  contract  provides  coverage for inpatient hospital
care,  benefits  for  in-patient  care  in  a  hospital  as  defined  by
subdivision  ten  of  section  1.03  of  the  mental  hygiene law or for
inpatient  care  provided  in  other  states,  to   similarly   licensed
hospitals,  and  benefits  for  out-patient  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 out-patient care provided in other states,  to
similarly certified 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
* (1)  where  the  contract  provides  coverage for inpatient hospital
care, benefits  for:  in-patient  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
(2) where the contract provides coverage for physician  services  such
contract  shall  provide  benefits  for  outpatient  care  provided by a
psychiatrist or psychologist licensed to practice in this  state,  or  a
mental health counselor, marriage and family therapist, or psychoanalyst
licensed  pursuant  to  article one hundred sixty-three of the education
law, or 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  nurse  practitioner licensed to
practice in  this  state,  or  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.
(3)  Such  coverage  may be subject to annual deductibles, co-pays and
coinsurance as may be deemed appropriate by the superintendent and shall
be consistent with those imposed on other benefits under  the  contract.
Provided  that no copayment or coinsurance imposed for outpatient mental
health services provided in a facility licensed, certified or  otherwise
authorized by the office of mental health shall exceed the copayments or
coinsurance imposed for a primary care office visit under the contract.
(4)   Coverage   under  this  subsection  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 contract.
(5) The  criteria  for  medical  necessity  determinations  under  the
contract  with respect to mental health benefits shall be made available
by the corporation to any insured, prospective  insured,  or  in-network
provider upon request.
(6) For purposes of this subsection:
(A)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that  a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement;
* (C)  "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
contract; 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
* (C)   "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
contract;
* 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
* (D) "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
* (D) "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
* (E) "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
* (F) "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
* (G)  "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
(7)  A  corporation shall provide coverage under this subsection, 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).
(8) This paragraph 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  corporation's  provider
network.  Where  the  contract  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  paragraph  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 corporation  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  corporation  to  ensure
that the facility is using the evidence-based and peer reviewed clinical
review  criteria  utilized  by  the corporation 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 paragraph shall also not be subject to concurrent review during the
first  thirty  days  of the inpatient or residential admission, provided
the facility notifies the corporation 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 corporation to ensure that the facility
is using the evidence-based and peer reviewed clinical  review  criteria
utilized  by  the  corporation 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  paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
(9) This paragraph 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 corporation's provider network. Benefits for
care  by  a  crisis  stabilization  center  shall  not  be  subject   to
preauthorization.  All  treatment  provided  under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
* (10) This  paragraph  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 paragraph, "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.
(A)  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 paragraph shall
prevent services provided subsequent to the provision of  mobile  crisis
intervention services from being subject to preauthorization.
(B)  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.
(C) If the covered services are provided by a non-participating mobile
crisis intervention services provider, a corporation  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.
(D) 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.
(E) 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 contract.
* 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
(11) This paragraph 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.   A   corporation   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
corporation 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  a
corporation  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,  a  corporation  for  the  services
provided  pursuant  to  this  paragraph,  except  for  the collection of
in-network copayments, coinsurance, or deductibles for which the insured
is responsible for under the terms of the contract.
* (12) This paragraph 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  corporation's
provider   network.   Reimbursement  for  covered  outpatient  treatment
provided by such facility shall  be  at  rates  negotiated  between  the
corporation 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 paragraph, 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  corporations  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, corporations may account for such  differences  in  future
premium  rate  filings  and applications submitted to the superintendent
for approval.
* NB Effective January 1, 2025
(j)(1) A health  service  corporation  or  medical  expense  indemnity
corporation    that   provides   medical,   major-medical   or   similar
comprehensive-type coverage shall provide coverage for the provision  of
preventive and primary care services.
(2)  For  purposes  of  this  paragraph  and  paragraph  one  of  this
subsection,  preventive  and  primary  care  services  shall  mean   the
following  services rendered to a covered child of a subscriber from the
date of birth through the attainment of nineteen years of age:
(A) 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,
(B) 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
(C)  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.
(D) Such coverage required pursuant to this  paragraph  and  paragraph
one  of  this  subsection  shall not be subject to annual deductibles or
coinsurance.
(E) Such coverage required pursuant to this  paragraph  and  paragraph
one of this subsection shall not restrict or eliminate existing coverage
provided by the contract.
(3)  In  addition  to  paragraph  one or two of this subsection, every
contract that provides hospital,  surgical  or  medical  care  coverage,
except  for  a  grandfathered  health  plan under paragraph four of this
subsection, shall provide coverage for the following preventive care and
screenings for subscribers, and such coverage shall not  be  subject  to
annual deductibles or coinsurance:
(A)   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;
(B)  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;
(C)  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
(D) with  respect  to  women,  such  additional  preventive  care  and
screenings  not  described  in subparagraph (A) of this paragraph and as
provided  for  in  comprehensive  guidelines  supported  by  the  health
resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage  provided  by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for  as  long  as  the  coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(k)(1) Every contract 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
contract.
(2)  Coverage  provided  under  this  subsection  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.
(3)  Coverage  provided under this subsection 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 contract.
(4)  This  paragraph  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 corporation's
provider  network.  Coverage provided under this subsection shall not be
subject to preauthorization. Coverage  provided  under  this  subsection
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 corporation 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 corporation 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 corporation 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  corporation  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 corporation which is designated by  the  office  of
alcoholism  and  substance  abuse  services.  Prior  to  discharge,  the
facility shall indicate to the corporation whether services included  in
the discharge plan are secured or determined to be reasonably available.
Any  utilization  review  of treatment provided under this paragraph 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 corporation
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 corporation 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   paragraph  other  than  any  copayment,
coinsurance, or deductible otherwise required under the contract.
(5) The  criteria  for  medical  necessity  determinations  under  the
contract with respect to inpatient substance use disorder benefits shall
be made available by the corporation to any insured, prospective insured
or in-network provider upon request.
(6) For purposes of this subsection:
(A)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B)  "predominant"  means  that  a  financial requirement or treatment
limitation is the most common or frequent  of  such  type  of  limit  or
requirement;
(C) "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 contract; and
(D)  "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.
(7)  A  corporation shall provide coverage under this subsection, 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).
(l) (1) Every contract 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 contract.
(2) Coverage under this subsection 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.
(3)  Coverage  provided under this subsection 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 contract.
(3-a)  A  contract  that  provides  large  group  coverage  under this
subsection shall not impose copayments  or  coinsurance  for  outpatient
substance use disorder services that exceed the copayment or coinsurance
imposed  for  a primary care office visit. Provided that no greater than
one such copayment may be imposed for all services provided in a  single
day  by  a  facility  licensed, certified or otherwise authorized by the
office of alcoholism and substance abuse services to provide  outpatient
substance use disorder services.
(4)  A contract providing coverage for substance use disorder services
pursuant to this subsection shall provide up to twenty outpatient visits

per contract 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  contract  pursuant to this subsection. The
coverage required by this subsection shall include treatment as a family
member pursuant to such  family  member's  own  contract  provided  such
family member:
(A)  does not exceed the allowable number of family visits provided by
the applicable contract pursuant to this subsection; and
(B) is otherwise entitled to coverage pursuant to this subsection  and
such family member's applicable contract.
(5)  This  paragraph  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 corporation's provider network. Coverage provided
under this subsection shall not be subject to preauthorization. Coverage
provided under this subsection 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 corporation 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
corporation  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 corporation 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 paragraph 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 corporation 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  corporation  which  is  designated  by  the  office  of
alcoholism and substance abuse services. A subscriber shall not have any
financial  obligation  to  the  facility  for  any  treatment under this
paragraph other than any copayment, coinsurance, or deductible otherwise
required under the contract.
(6) The  criteria  for  medical  necessity  determinations  under  the
contract  with  respect  to  outpatient  substance use disorder benefits
shall be made available by the corporation to any  insured,  prospective
insured, or in-network provider upon request.
(7) For purposes of this subsection:
(A)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that  a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement.
(C) "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 contract; and
(D)  "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.
(8)  A  corporation shall provide coverage under this subsection, 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).
(9) This paragraph 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 corporation's provider network. Benefits for
care  in  a  crisis  stabilization  center  shall  not  be  subject   to
preauthorization.  All  treatment  provided  under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
* (10) This paragraph 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 corporation's provider network. Reimbursement for
covered outpatient treatment provided by such  facilities  shall  be  at
rates negotiated between the corporation 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 paragraph, 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  corporations 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, corporations  may
account  for  such  differences  in  future  premium  rate  filings  and
applications submitted to the superintendent for approval.
* NB Effective January 1, 2025
(l-1) (A) No contract that provides medical, major medical or  similar
comprehensive-type  individual  or  small  group  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 contract, 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. Every contract that provides medical,
major medical, or similar comprehensive-type large group coverage  shall
provide coverage for prescription drugs for medication for the treatment
of  a  substance  use disorder and shall not require prior authorization
for an  initial  or  renewal  prescription  for  the  detoxification  of
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
individual  covered  under the contract, 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.
(l-2)  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.
(m)  A  medical  expense  indemnity  corporation  or  a health service
corporation which provides coverage for any service  within  the  lawful
scope  of practice of a duly licensed registered professional nurse must
make  available,  and  if  requested  by  all  subscribers  in  a  group
remittance  group,  or  by  a  contract  holder  in  the case of a group
contract issued pursuant to section four thousand three hundred five  of
this  chapter, provide reimbursement for such services when performed by
a duly licensed registered professional nurse  provided,  however,  that
reimbursement  shall  not  be  made  for  nursing services provided to a
subscriber in a general hospital, nursing home, or a facility  providing
health   related   services,  as  such  terms  are  defined  in  section
twenty-eight hundred one of the public health law, or in a facility,  as
such  term  is  defined in subdivision six of section 1.03 of the mental
hygiene law, or in a physician's office. Such coverage may be subject to
annual deductibles and co-insurance as may be deemed appropriate by  the
superintendent  and  are consistent with those imposed on other benefits
within a given policy. Such coverage  shall  not  replace,  restrict  or
eliminate  existing  coverage  provided  by the policy. Coverage for the
services of a  duly  licensed  registered  professional  nurse  need  be
provided  only  if  the  nature  of  the  patient's illness or condition
requires nursing care which can appropriately be provided  by  a  person
with  the  education and professional skill of a registered professional
nurse and the  nursing  care  is  necessary  in  the  treatment  of  the
patient's  illness  or  condition. Written notice of the availability of
such coverage shall be delivered to the group remitting agent  or  group
contract  holder  prior  to  inception  of  such  contract  and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure  was
the  subject of collective bargaining affecting persons who are employed
in more than one state.
(n) Every health service  or  medical  expense  indemnity  corporation
issuing  a group contract pursuant to this section or a group remittance
contract  for  delivery  in   this   state   which   contract   provides

reimbursement   to   subscribers   or   physicians,   psychiatrists   or
psychologists for psychiatric  or  psychological  services  or  for  the
diagnosis  and treatment of mental health conditions, however defined in
such  contract,  must provide the same coverage to persons covered under
the group contract for  such  services  when  performed  by  a  licensed
clinical  social worker, within the lawful scope of his or her practice,
who is licensed pursuant  to  article  one  hundred  fifty-four  of  the
education  law  and  a  mental  health  counselor,  marriage  and family
therapist, or psychoanalyst licensed pursuant  to  article  one  hundred
sixty-three  of  the education law. 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. The
state board for social work  shall  maintain  a  list  of  all  licensed
clinical   social   workers   qualified  for  reimbursement  under  this
subsection. The  state  board  for  mental  health  practitioners  shall
maintain  a  list of all licensed mental health counselors, marriage and
family therapists, or psychoanalysts qualified for  reimbursement  under
this subsection.
(o)  A  hospital  service  corporation or a health service corporation
which provides coverage for inpatient hospital care must make  available
and, if requested by all persons holding individual contracts in a group
whose premiums are paid by a remitting agent or by the contractholder in
the  case  of  a group contract issued pursuant to section four thousand
three hundred five of this article, provide coverage for  hospice  care.
For  the  purposes  of this subsection, hospice care shall mean the care
and treatment of a  covered  person  who  has  been  certified  by  such
person's  primary attending physician as having a life expectancy of six
months or less and which is provided by a hospice organization certified
pursuant to article forty of the public health law or  under  a  similar
certification  process  required  by  the  state  in  which  the hospice
organization is located. Hospice care coverage shall be at  least  equal
to:  (1)  a total of two hundred ten days of coverage beginning with the
first day on which care is provided, for inpatient  hospice  care  in  a
hospice  or in a hospital and home care and outpatient services provided
by the hospice, including drugs  and  medical  supplies,  and  (2)  five
visits  for  bereavement counseling services, either before or after the
insured's death, provided to the family of the terminally  ill  insured.
Such  coverage  shall  be  made  available  at  the inception of all new
contracts and, with respect to contracts  issued  before  the  effective
date of this provision, at the first annual anniversary date thereafter,
without   evidence   of   insurability  and  at  any  subsequent  annual
anniversary date subject to evidence of insurability. Such coverage  may
be  subject  to  annual  deductibles  and  coinsurance  as may be deemed
appropriate by the superintendent and are consistent with those  imposed
on  other benefits within a given contract period. Written notice of the
availability of such coverage shall be delivered to the group  remitting
agent  or  group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a policy covers two hundred or  more  employees  or  where  the  benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(p)  (1)  A  medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides  coverage  for
hospital,  surgical or medical care shall provide the following coverage
for mammography screening for occult breast cancer:
(A) 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;
(B)  a  single  baseline  mammogram,  which  may be provided by breast
tomosynthesis, for covered persons aged thirty-five through thirty-nine,
inclusive;
(C) an annual mammogram, which may be provided by breast tomosythesis,
for covered persons aged forty and older;
(D) for large group contracts offered by a medical  expense  indemnity
corporation,   a  hospital  service  corporation  or  a  health  service
corporation that provide coverage  for  hospital,  surgical  or  medical
care,  an  annual mammogram for covered persons aged thirty-five through
thirty-nine, inclusive, upon the recommendation of a physician,  subject
to  the  corporation's  determination  that  the  mammogram is medically
necessary; and
(E) The coverage required in this paragraph or paragraph two  of  this
subsection shall not be subject to annual deductibles or coinsurance.
(2)  For  purposes  of  paragraph  one of this subsection, 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 tomosythesis.
(3) In addition to paragraph one or  two  of  this  subsection,  every
contract  that provides coverage for hospital, surgical or medical care,
except for a grandfathered health plan  under  paragraph  four  of  this
subsection,   shall  provide  coverage  for  the  following  mammography
screening services, and such coverage shall not  be  subject  to  annual
deductibles or coinsurance:
(A)  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
(B)  with  respect  to  women,  such  additional  preventive  care and
screenings for mammography not described in  subparagraph  (A)  of  this
paragraph  and  as provided for in comprehensive guidelines supported by
the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual  was  enrolled
on  March  twenty-third,  two  thousand  ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(5) Screening and diagnostic  imaging  for  the  detection  of  breast
cancer, including diagnostic mammograms, breast ultrasounds, or magnetic
resonance  imaging,  covered  under the contract shall not be subject to
annual deductibles or coinsurance.
* (p-1) (1)  A  medical  expense  indemnity  corporation,  a  hospital
service  corporation  or  a  health  service  corporation  that provides
coverage for  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:
(A)  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;
(B)  centers  for  medicare  and  medicaid  services national coverage
determinations or  medicare  administrative  contractor  local  coverage
determinations;
(C) nationally recognized clinical practice guidelines; or
(D)  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.
(2)  Such  coverage  shall  be  provided  in a manner that shall limit
disruptions  in  care  including  the  need  for  multiple  biopsies  or
biospecimen samples.
(3)  As  used  in  this subsection, the following terms shall have the
following meanings:
(A)  "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.
(B)  "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.
(C)  "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
(q)  (1)  Every  policy  issued  by  a   medical   expense   indemnity
corporation,   a  hospital  service  corporation  or  a  health  service
corporation 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.
(2) Notwithstanding the provisions of this subsection, 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  subsection  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.
(q-1) (1)  Every  contract  issued  by  a  medical  expense  indemnity
corporation,   a  hospital  service  corporation  or  a  health  service
corporation for delivery in this  state  that  provides  medical,  major
medical or similar comprehensive-type coverage and provides coverage for
prescription  drugs  and 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.
(2) An  insurer  providing  coverage  under  this  paragraph  and  any
participating  entity  through  which the insurer offers health services
shall not:
(A) vary the terms of the contract for the purpose or with the  effect
of avoiding compliance with this paragraph;
(B)  provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under  this
paragraph;
(C)  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;
(D) 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
(E) achieve compliance with this paragraph by imposing an increase  in
cost sharing for an intravenous or injected anticancer medication.
(r)  Consistent  with federal law, a hospital service corporation or a
health service corporation 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 a  person
holding  a  direct payment individual contract or by all persons holding
individual contracts in a group whose premiums are paid by  a  remitting
agent  or  by  a  contract holder in the case of a group contract issued
pursuant to section four thousand three hundred five  of  this  article,
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  when  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 contracts and, with respect to all
other contracts at each anniversary date of the contract.
(1)  Coverage  shall  be subject to a copayment of twenty-five dollars
per day.
(2) Brochures describing such coverage must be provided at the time of
application for all new contracts and  thereafter  on  each  anniversary
date  of  the contract, and with respect to all other contracts annually
at each anniversary  date  of  the  contract.  Such  brochures  must  be
approved  by the superintendent in consultation with the commissioner of
health.
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.
(3)  The  commensurate  rate  for the coverage must be approved by the
superintendent.
* (s) (1) A hospital service corporation or health service corporation
which provides coverage for hospital care shall not exclude coverage for
hospital  care  for  diagnosis  and  treatment  of  correctable  medical
conditions  otherwise  covered  by the policy solely because the medical
condition results in infertility; provided, however that:
(A) subject to the provisions of paragraph three of  this  subsection,
in  no  case  shall such coverage exclude surgical or medical procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
(B) provided, further however,  that  subject  to  the  provisions  of
paragraph  three  of  this  subsection,  in  no case shall such coverage
exclude diagnostic  tests  and  procedures  provided  as  part  of  such
hospital  care  that  are necessary to determine infertility or that are
necessary in connection with  any  surgical  or  medical  treatments  or
prescription   drug  coverage  provided  pursuant  to  this  subsection,
including such diagnostic tests and procedures  as  hysterosalpingogram,
hysteroscopy,  endometrial  biopsy,  laparoscopy, sono-hysterogram, post
coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
and
(C) provided,  further  however,  every  such  policy  which  provides
coverage  for  prescription  drugs  shall include, within such coverage,
coverage for prescription drugs approved by the federal  Food  and  Drug
Administration  for use in the diagnosis and treatment of infertility in
accordance with paragraph three of this subsection.
(2) A medical expense indemnity or health  service  corporation  which
provides  coverage  for  surgical  and  medical  care  shall not exclude
coverage for surgical and medical care for diagnosis  and  treatment  of
correctable  medical  conditions  otherwise covered by the policy solely
because the medical condition results in infertility; provided,  however
that:
(A)  subject  to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical  or  medical  procedures
which  would  correct  malformation, disease or dysfunction resulting in
infertility; and
(B) provided, further however,  that  subject  to  the  provisions  of
paragraph  three  of  this  subsection,  in  no case shall such coverage
exclude diagnostic tests and procedures that are necessary to  determine
infertility  or  that  are  necessary in connection with any surgical or
medical treatments or prescription drug coverage  provided  pursuant  to
this  subsection,  including  such  diagnostic  tests  and procedures as
hysterosalpingogram,  hysteroscopy,  endometrial  biopsy,   laparoscopy,
sono-hysterogram,  post  coital  tests,  testis  biopsy, semen analysis,
blood tests and ultrasound; and
(C) provided,  further  however,  every  such  policy  which  provides
coverage  for  prescription  drugs  shall include, within such coverage,
coverage for prescription drugs approved by the federal  Food  and  Drug
Administration  for use in the diagnosis and treatment of infertility in
accordance with paragraph three of this subsection.
(3)  Coverage  of  diagnostic  and  treatment  procedures,   including
prescription drugs used in the diagnosis and treatment of infertility as
required  by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
(A) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this paragraph.
(B)   Coverage   may   be  subject  to  co-payments,  coinsurance  and
deductibles as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
policy.
(C) Except as provided in subparagraphs (F) and (G) of this paragraph,
coverage shall not be required to include the diagnosis and treatment of
infertility in connection  with:  (i)  in  vitro  fertilization,  gamete
intrafallopian  tube  transfers or zygote intrafallopian tube transfers;
(ii)  the  reversal  of  elective  sterilizations;  (iii)   sex   change
procedures;  (iv)  cloning;  or  (v)  medical  or  surgical  services or
procedures that  are  deemed  to  be  experimental  in  accordance  with
clinical guidelines referenced in subparagraph (D) of this paragraph.
(D)  The  superintendent,  in  consultation  with  the commissioner of
health,  shall  promulgate  regulations  which   shall   stipulate   the
guidelines  and  standards  which  shall  be  used  in  carrying out the
provisions of this paragraph, which shall include:
(i) The identification of experimental procedures and  treatments  not
covered  for  the  diagnosis  and treatment of infertility determined in
accordance with the standards and guidelines established and adopted  by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
(ii) The identification of the required training, experience and other
standards  for health care providers for the provision of procedures and
treatments for the diagnosis and treatment of infertility determined  in
accordance  with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine; and
(iii) The determination  of  appropriate  medical  candidates  by  the
treating  physician  in  accordance  with  the  standards and guidelines
established and adopted by the American  College  of  Obstetricians  and
Gynecologists and/or the American Society for Reproductive Medicine.
(E)(i)  For  the  purposes  of  this subsection, "infertility" means a
disease or condition  characterized  by  the  incapacity  to  impregnate
another  person  or  to  conceive, defined by the failure to establish a
clinical pregnancy after twelve months of  regular,  unprotected  sexual
intercourse  or  therapeutic  donor insemination, or after six months of
regular,   unprotected   sexual   intercourse   or   therapeutic   donor
insemination  for  a  female  thirty-five years of age or older. Earlier
evaluation and treatment may  be  warranted  based  on  an  individual's
medical history or physical findings.
(ii)  For  purposes of this subsection, "iatrogenic infertility" means
an impairment of fertility by surgery, radiation, chemotherapy or  other
medical treatment affecting reproductive organs or processes.
(F)  Coverage  shall  also  include  standard  fertility  preservation
services when a medical  treatment  may  directly  or  indirectly  cause
iatrogenic  infertility to an insured. Coverage may be subject to annual
deductibles and coinsurance, including  copayments,  as  may  be  deemed
appropriate  by  the  superintendent  and  as  are consistent with those
established for other benefits within a given contract.
(G) Every large group contract that provides medical, major medical or
similar comprehensive-type coverage shall  provide  coverage  for  three
cycles  of  in-vitro fertilization used in the treatment of infertility.
Coverage may be subject to annual deductibles and coinsurance, including
copayments, as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given

contract. For purposes of this subparagraph, a  "cycle"  is  defined  as
either  all  treatment  that  starts  when:  preparatory medications are
administered for ovarian  stimulation  for  oocyte  retrieval  with  the
intent  of  undergoing  in-vitro  fertilization  using  a  fresh  embryo
transfer; or medications are administered  for  endometrial  preparation
with  the  intent  of  undergoing  in-vitro fertilization using a frozen
embryo transfer.
(H) No corporation providing  coverage  under  this  subsection  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.
(4)  Every contract issued by a medical expense indemnity corporation,
a hospital service corporation or a  health  services  corporation  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  corporation  has  established  for  the  network
participating mail order or other non-retail pharmacy. In such case, the
contract shall not impose any fee, co-payment, co-insurance,  deductible
or  other condition on any covered person who does not elect to purchase
prescription fertility drugs through a network participating mail  order
or  other non-retail pharmacy; provided, however, that the provisions of
this section shall not supersede the terms of  a  collective  bargaining
agreement  or  apply  to  a  contract that is the result of a collective
bargaining agreement between an employer and a recognized  or  certified
employee organization.
* NB There are 2 sb (s)'s
* (s)  Notwithstanding any provision of a contract issued by a medical
expense indemnity corporation, a dental expense indemnity corporation or
health service corporation, every contract which provides  coverage  for
care  provided  through  licensed  health professionals who can bill for
services shall provide the same  coverage  and  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.
* NB There are 2 sb (s)'s
(t)  (1)  A  medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides  coverage  for
hospital, surgical, or medical care shall provide coverage for an annual
cervical cytology screening for cervical cancer and its precursor states
for  women  aged  eighteen  and  older.  Such  coverage required by 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 contract.
(2)  For  purposes  of  paragraph  one  of  this  subsection, 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.
(3) In addition to paragraph one or  two  of  this  subsection,  every
contract  that provides coverage for hospital, surgical or medical care,

except for a grandfathered health plan  under  paragraph  four  of  this
subsection,  shall  provide coverage for the following cervical cytology
screening services, and such coverage shall not  be  subject  to  annual
deductibles or coinsurance:
(A)  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
(B)  with  respect  to  women,  such  additional  preventive  care and
screenings for cervical cytology not described in  subparagraph  (A)  of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage  provided  by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for  as  long  as  the  coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(u)  (1)  A  medical expense indemnity corporation or a health service
corporation 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.
* (2)  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
* (2)  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
(3)  This  subsection shall not apply to a policy which covers persons
employed in more than one state or the benefit structure  of  which  was
the  subject of collective bargaining affecting persons employed in more
than one state unless such policy is issued under  the  New  York  state
health  insurance  plan  established  under  article eleven of the civil
service law or issued to or through a local government.
(u-1) A medical expense indemnity  corporation  or  a  health  service
corporation  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 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 subsection 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  four  thousand  three  hundred
six-h of this article.
(v)   (1)  Every  contract  issued  by  a  medical  expense  indemnity
corporation, hospital service corporation or health service  corporation
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 after such
covered person has undergone a lymph node dissection or a lumpectomy for
the treatment of breast cancer or a mastectomy covered by the  contract.
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
group remitting agent or group contract holder prior to the inception of
such contract and annually thereafter.
(2)  A  medical  expense  indemnity  corporation,   hospital   service
corporation  or health service corporation which provides coverage under
this subsection and any participating entity through which  the  insurer
offers health services shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll  or to renew coverage under the terms of the contract or vary the
terms of the contract for the purpose or with  the  effect  of  avoiding
compliance with this subsection;
(B)  provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under  this
subsection;
(C)  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 subsection;
(D)  provide  incentives  (monetary  or  otherwise)  to  a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
subsection  intended  to  induce  or  have  the  effect of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this subsection; or
(E)  restrict  coverage  for any portion of a period within a hospital
length of stay required under this  subsection  in  a  manner  which  is
inconsistent  with  the  coverage  provided for any preceding portion of
such stay.
(3) The prohibitions in paragraph two of this subsection shall  be  in
addition  to  the  provisions  of  sections  four thousand three hundred
seventeen and four thousand three hundred eighteen of this  article  and
nothing  in  this  paragraph  shall  be construed to suspend, supersede,
amend or otherwise modify such sections.
(w)(1)  Every  contract  issued  by  a   medical   expense   indemnity
corporation  or health service corporation 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 contract that  requires,  or  provides  financial
incentives  for,  the  covered  person  to receive covered services from
health care providers participating in a provider network maintained  by
or  under  contract  with  the  corporation,  the contract 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 covered person beyond what such covered
person would have paid for services  from  a  participating  appropriate
specialist.  Provided  however  that  nothing  herein  shall  impair the
covered person's rights (if any) under the contract 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 contract  for  services  provided  by  non-participating
providers.   The  corporation  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  contract  that  does  not  provide  financial
incentives  for,  and  does  not  require, the covered person to receive
covered services from health care providers participating in a  provider
network  maintained  by  or  under  contract  with  the corporation, the
contract shall include coverage for a  second  medical  opinion  from  a
specialist  at  no additional cost to the covered person beyond what the
covered person would have paid for comparable services covered under the
contract.
(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
contract  and,  where  applicable,  consistent  with  the  provisions of
subparagraphs (i) and (ii) of this paragraph.
Nothing  in  this  subsection  shall   eliminate   or   diminish   the
corporation's  obligation  to comply with the provisions of section four
thousand eight hundred four  of  this  chapter  and  section  forty-four
hundred  three of the public health law where applicable. Written notice
of  the  availability  of  such coverage shall be delivered to the group
remitting agent or group contract holder prior to the inception of  such
contract and annually thereafter.
(2)   A  medical  expense  indemnity  corporation  or  health  service
corporation which  provides  coverage  under  this  subsection  and  any
participating  entity  through  which the insurer offers health services
shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the contract or vary  the
terms  of  the  contract  for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a  covered
person  to accept less than the minimum protections available under this
subsection;
(C) 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 subsection; or
(D)  provide  incentives  (monetary  or  otherwise)  to  a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
subsection  intended  to  induce  or  have  the  effect of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this subsection.
(3)  The  prohibitions in paragraph two of this subsection shall be in
addition to the provisions  of  sections  four  thousand  three  hundred
seventeen  and  four thousand three hundred eighteen of this article and
nothing in this paragraph shall  be  construed  to  suspend,  supersede,
amend or otherwise modify such sections.
(x)   (1)  Every  contract  issued  by  a  medical  expense  indemnity
corporation, hospital service corporation or health service  corporation
which  provides  coverage for surgical or medical care shall provide the
following coverage for breast or chest wall reconstruction surgery after
a mastectomy or partial mastectomy:
(A) all stages of reconstruction of the breast or chest wall on  which
the mastectomy or partial mastectomy has been performed; and
(B)  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 or
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 group remitting agent or group
contract holder prior to the inception of  such  contract  and  annually
thereafter.
(2)   A   medical  expense  indemnity  corporation,  hospital  service
corporation or health service corporation which provides coverage  under
this  subsection  and any participating entity through which the insurer
offers health services shall not:
(A) 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 subsection;
(B) provide incentives (monetary or otherwise) to encourage a  covered
person  to accept less than the minimum protections available under this
subsection;
(C)  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 subsection;
(D) provide incentives  (monetary  or  otherwise)  to  a  health  care
practitioner   relating  to  the  services  provided  pursuant  to  this
subsection intended to induce  or  have  the  affect  of  inducing  such
practitioner   to   provide  care  to  a  covered  person  in  a  manner
inconsistent with this subsection;
(E) restrict coverage for any portion of a period  within  a  hospital
length  of  stay  required  under  this  subsection in a manner which is
inconsistent with the coverage provided for  any  preceding  portion  of
such stay; or
(F)  the  prohibitions  in  this paragraph shall be in addition to the
provisions of sections four thousand three hundred  seventeen  and  four
thousand  three  hundred  eighteen  of  this article and nothing in this
paragraph shall be construed to suspend, supersede, amend  or  otherwise
modify such sections.
* (y)  Every  contract  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 sb§ (y)'s
* (y)(1) Every contract issued by a health service  corporation  or  a
medical  expense indemnity corporation which is a "managed care product"
as defined in paragraph four of this subsection that  includes  coverage
for  physician services in a physician's office, and every "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.
(3) Every contract issued by a health service corporation or a medical
expense  indemnity  corporation  which  includes  coverage for physician
services in a physician's office,  and  every  contract  which  provides
major  medical  or  similar  comprehensive-type  coverage,  other than a
"managed care product" as defined in paragraph four of this  subsection,
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 contract 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.
(4)  For  purposes  of this subsection, a "managed care product" shall
mean 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  corporation'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

corporation's managed care provider network, in order for the insured to
be entitled to the maximum reimbursement under the contract.
(5)  The coverage required by this subsection shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 sb§ (y)'s
(z) No contract issued by a medical expense indemnity  corporation,  a
hospital  service  corporation  or  a  health  service corporation 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  subsection
shall  be  provided  subject  to  the  terms  and  conditions  generally
applicable to other benefits provided under the policy.
(z-1) (1) 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:
(A) 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
(B) 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.
(2)  Such  coverage  shall  not  be  subject  to annual deductibles or
coinsurance.
(aa)(1) Every contract issued by a hospital service company or  health
service   corporation   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.
(2) 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 subsection, except for the collection of copayments, coinsurance or
deductibles  for which the insured is responsible for under the terms of
the policy.
*(3)  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
* (3)  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
* (4) The provisions of this subsection shall have no  application  to
transfers  of patients between hospitals or health care facilities by an
ambulance service as described in paragraph one of this subsection.
* NB Effective until January 1, 2025
* (4) The provisions of this subsection shall have no  application  to
transfers  of patients between hospitals or health care facilities by an
ambulance service as described  in  paragraph  one  of  this  subsection
unless such services are covered under the policy.
* NB Effective January 1, 2025
(5) As used in this subsection:
(A)   "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 subsection, 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.
(B) "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.
(bb) A  health  service  corporation  or  a  medical  service  expense
indemnity   corporation   that   provides   major   medical  or  similar
comprehensive-type coverage shall provide such coverage for bone mineral
density measurements or tests, and if such contract  otherwise  includes
coverage  for  prescription  drugs,  drugs  and  devices approved by the
federal food and drug administration or generic equivalents as  approved

substitutes.  In determining appropriate coverage provided by paragraphs
one, two and three of this subsection, the insurer or health maintenance
organization shall adopt standards that  include  the  criteria  of  the
federal  Medicare program and the criteria of the national institutes of
health for the detection of osteoporosis, provided  that  such  coverage
shall be further determined as follows:
(1)  For purposes of paragraphs two and three of this subsection, bone
mineral density measurements or tests, drugs and devices  shall  include
those covered under the criteria of the federal Medicare program as well
as  those  in accordance with the criteria of the national institutes of
health, including, as consistent with such criteria,  dual-energy  x-ray
absorptiometry.
(2)  For purposes of paragraphs one and three of this subsection, bone
mineral density measurements  or  tests,  drugs  and  devices  shall  be
covered  for  individuals  meeting the criteria for coverage, consistent
with the criteria under the federal Medicare program or the criteria  of
the  national  institutes  of  health;  provided  that,  to  the  extent
consistent with  such  criteria,  individuals  qualifying  for  coverage
shall, at a minimum, include individuals:
(i)  previously  diagnosed  as  having osteoporosis or having a family
history of osteoporosis; or
(ii) with symptoms or conditions indicative of the  presence,  or  the
significant risk, of osteoporosis; or
(iii)  on  a  prescribed  drug  regimen  posing  a significant risk of
osteoporosis; or
(iv) with lifestyle factors to such a degree as posing  a  significant
risk of osteoporosis; or
(v)  with  such age, gender and/or other physiological characteristics
which pose a significant risk for osteoporosis.
(3) Such coverage required pursuant to paragraph one or  two  of  this
subsection  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.
(4)  In  addition  to  paragraph one, two or three of this subsection,
every  contract  that  provides  hospital,  surgical  or  medical   care
coverage, except for a grandfathered health plan under paragraph five of
this  subsection,  shall  provide  coverage  for  the following items or
services for bone mineral  density,  and  such  coverage  shall  not  be
subject to annual deductibles or coinsurance:
(A)  evidence-based  items  or  services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations  of
the United States preventive services task force; and
(B)  with  respect  to  women,  such  additional  preventive  care and
screenings for bone mineral density not described in subparagraph (A) of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(5) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual  was  enrolled
on  March  twenty-third,  two  thousand  ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(cc) (1) Every contract  that  provides  medical,  major  medical,  or
similar  comprehensive  type  coverage that is issued, amended, renewed,
effective or delivered on or after January first, two  thousand  twenty,
shall   provide   coverage   for  all  of  the  following  services  and
contraceptive methods:
(A) All FDA-approved contraceptive drugs, devices, and other products.
This includes all  FDA-approved  over-the-counter  contraceptive  drugs,

devices,  and  products  as  prescribed or as otherwise authorized under
state or federal law. The following applies to this coverage:
(i)   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 subsection;
(ii) 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. 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;
(iii) this coverage  shall  include  emergency  contraception  without
cost-sharing  when  provided  pursuant  to a prescription or order under
section sixty-eight hundred thirty-one of  the  education  law  or  when
lawfully provided over the counter; and
(iv)  this  coverage  must  allow  for  the dispensing of up to twelve
months worth of a contraceptive at one time;
(B) 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;
(C) Patient education and counseling on contraception; and
(D) Follow-up services related to the drugs,  devices,  products,  and
procedures covered under this subsection, including, but not limited to,
management  of  side  effects,  counseling  for continued adherence, and
device insertion and removal.
(2)  A  contract  subject  to  this  subsection  shall  not  impose  a
deductible,   coinsurance,   copayment,   or   any   other  cost-sharing
requirement on the coverage provided pursuant to this subsection.
(3) Except as otherwise authorized under this subsection,  a  contract
shall  not  impose  any  restrictions or delays on the coverage required
under this subsection.
(4) Benefits for an enrollee under this subsection shall be  the  same
for  an  enrollee's  covered  spouse  or  domestic  partner  and covered
nonspouse dependents.
(5)  Notwithstanding  any  other  provision  of  this  subsection,   a
religious  employer  may request a contract without coverage for federal
food and drug administration approved  contraceptive  methods  that  are
contrary  to the religious employer's religious tenets. If so requested,
such contract shall  be  provided  without  coverage  for  contraceptive
methods.    This  paragraph  shall  not be construed to deny an enrollee
coverage of, and timely access to, contraceptive methods.
(A) For purposes of this subsection,  a  "religious  employer"  is  an
entity for which each of the following is true:
(i) The inculcation of religious values is the purpose of the entity.
(ii)  The  entity  primarily  employs  persons who share the religious
tenets of the entity.
(iii)  The  entity  serves  primarily  persons who share the religious
tenets of the entity.
(iv) The entity is a nonprofit organization as  described  in  Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(B) Every religious employer that invokes the exemption provided under
this  paragraph  shall  provide  written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
(6) (A) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
five of this subsection, each enrollee covered under the contract issued
to that group contractholder shall have the right to  directly  purchase
the  rider  required  by  this  subsection  from  the  insurer or health
maintenance  organization  which  issued  the  group  contract  at   the
prevailing  small group community rate for such rider whether or not the
employee is part of a small group.
(B) Where a group contractholder makes an  election  not  to  purchase
coverage for contraceptive drugs or devices in accordance with paragraph
five  of this subsection, the insurer or health maintenance organization
that provides such coverage shall provide written  notice  to  enrollees
upon  enrollment  with the insurer or health maintenance organization of
their right to directly purchase a rider for coverage for  the  cost  of
contraceptive  drugs  or  devices.  The  notice  shall  also  advise the
enrollees of the additional premium for such coverage.
(7) Nothing in this subsection shall be  construed  as  authorizing  a
contract  which  provides  coverage  for  prescription  drugs to exclude
coverage for  prescription  drugs  prescribed  for  reasons  other  than
contraceptive purposes.
(8)   For   the   purposes   of   this   paragraph,  "over-the-counter
contraceptive products"  shall  mean  those  products  provided  for  in
comprehensive  guidelines supported by the health resources and services
administration as of January twenty-first, two thousand nineteen.
(dd)  No  health  service  corporation  or  medical  service   expense
indemnity  corporation  which provides medical, major medical or similar
comprehensive-type coverage shall exclude coverage for services  covered
under  such  policy  when  provided  by  a comprehensive care center for
eating disorders pursuant to article thirty of the mental  hygiene  law;
provided,  however,  that reimbursement by such corporation for services
provided through such comprehensive care centers shall,  to  the  extent
possible  and  practicable,  be structured in a manner to facilitate the
individualized, comprehensive and integrated plans of  care  which  such
centers' network of practitioners and providers are required to provide.
(ee)  (1)  A medical expense indemnity corporation, a hospital service
corporation or a health service corporation which provides coverage  for
hospital  or  surgical  care  coverage  shall  not  exclude coverage for
screening, diagnosis  and  treatment  of  medical  conditions  otherwise
covered  by  the  contract  solely  because the treatment is provided to
diagnose or treat autism spectrum disorder.
(2) Every contract 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 contract 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 contract. This paragraph shall not  be  construed  as
limiting  the  benefits  that  are  otherwise available to an individual
under  the  contract,  provided  however  that  such  contract 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.
(3) For purposes of this subsection:
(A) "autism  spectrum  disorder"  means  any  pervasive  developmental
disorder  as  defined  in  the most recent edition of the diagnostic and
statistical manual of mental disorders.
(B) "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.
(C)  "behavioral  health  treatment"  means  counseling  and treatment
programs, when provided by a licensed  provider,  and  applied  behavior
analysis,  when  provided  by  a  person  that is 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.
(D)  "diagnosis  of  autism  spectrum  disorder"  means   assessments,
evaluations,  or  tests  to  diagnose  whether  an individual has autism
spectrum disorder.
(E) "pharmacy care" means medications prescribed by a licensed  health
care  provider  legally authorized to prescribe under title eight of the
education law.
(F) "psychiatric care" means direct or consultative services  provided
by  a  psychiatrist  licensed  in  the  state  in which the psychiatrist
practices.
(G)  "psychological  care"  means  direct  or  consultative   services
provided   by  a  psychologist  licensed  in  the  state  in  which  the
psychologist practices.
(H)  "therapeutic  care"  means  services  provided  by  licensed   or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(I)   "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:
(i) behavioral health treatment;
(ii) psychiatric care;
(iii) psychological care;
(iv) medical care provided by a licensed health care provider;
(v)  therapeutic  care,  including  therapeutic  care  which is deemed
habilitative or nonrestorative, in the event that  the  policy  provides
coverage for therapeutic care; and
(vi)  pharmacy  care  in the event that the contract provides coverage
for prescription drugs.
(4) 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.
(5) Nothing in this  subsection  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.
(7) Nothing in  this  subsection  shall  be  construed  to  prevent  a
contract  from  providing  services  through  a network of participating
providers  who  shall  meet  certain  requirements  for   participation,
including provider credentialing.
(8)   Coverage   under  this  subsection  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.
(9)  The  criteria  for  medical  necessity  determinations  under the
contract with respect to autism spectrum disorder benefits shall be made
available by the corporation to any  insured,  prospective  insured,  or
in-network provider upon request.
(10) For purposes of this subsection:
(A)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that  a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement; and
(C) "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 contract.
(11) A corporation shall provide coverage under this subsection, 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).
(ff)  (1)  No  managed  care  contract  issued  by  a  health  service
corporation, hospital service corporation or medical  expense  indemnity
corporation  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.
(2)  No  managed care contract issued by a health service corporation,
hospital service corporation or medical  expense  indemnity  corporation
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.
(3)  For  purposes  of  this subsection, 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.
(4) For purposes of this subsection, a "managed care  contract"  is  a
contract   that  requires  that  services  be  provided  by  a  provider
participating in the corporation's network in order for  the  subscriber
to receive the maximum level of reimbursement under the contract.
(gg)  (1)  Every  contract  issued  by a hospital service corporation,
health service corporation or medical expense indemnity corporation 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:
(A)  The  out-of-network  provider  is  duly  licensed to practice and
authorized to provide such treatment;
(B) The out-of-network provider is located outside the service area of
the insurer;
(C) The in-network healthcare provider treating the covered person for
the condition issues a written order for dialysis treatment stating that
in his or her opinion such treatment is necessary;
(D) The covered person has notified, in writing,  the  corporation  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  subparagraph  (C) of this paragraph. In the
event the covered person must travel on sudden notice due to  family  or
other  emergency,  shorter  notice  may  be permitted, provided that the
corporation  has  reasonable  opportunity  to  review  the  travel   and
treatment plans of the covered person;
(E)  The  corporation shall have the right to pre-approve the dialysis
treatment and schedule; and
(F) Such coverage is limited to no  greater  than  ten  out-of-network
treatments in a calendar year.
(2)  Where  coverage for out-of-network dialysis treatment is provided
pursuant to paragraph one of this subsection, no  corporation  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  corporation  shall  be the responsibility of the covered person
receiving the out-of-network services.
(3) Such coverage of  out-of-network  dialysis  services  required  by
paragraph  one  of  this  subsection  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.
(hh)  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 subsection,
shall, to the extent practicable, be limited in quantity so  as  not  to
exceed  the  remaining dosage initially approved for coverage. Provided,
further, that  such  limited  refilling  shall  not  limit  or  restrict
coverage   with  regard  to  any  previously  or  subsequently  approved
prescription for eye drop medication and shall be subject to  the  terms
and  conditions  of  the  policy  otherwise applicable to this coverage.
Provided,  further,  that  a  pharmacist  may  contact  the  prescribing
physician or health care provider to verity the prescription.
(ii)  Every contract issued by a corporation subject to the provisions
of this  article  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.
(jj)  No  medical  expense  indemnity  corporation, a hospital service
corporation or a health service corporation 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).
(kk) (1) Definitions. For the purpose of this subsection:
(A) "Same reimbursement amount" shall mean that any coverage described
under paragraph two of this subsection 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  health  benefit  plan  regardless  of  whether a
pharmacy is a mail order pharmacy or a non-mail order pharmacy.
(B) "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.
(2)  Any contract issued by a medical expense indemnity corporation, a
hospital service corporation  or  a  health  services  corporation  that
provides  coverage  for  prescription  drugs  shall  permit each covered
person to fill any covered  prescription  that  may  be  obtained  at  a
network  participating  mail  order or other non-retail pharmacy, at the
covered person'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
corporation  has established for the network participating mail order or
other non-retail pharmacy. In such a case, the contract shall not impose
a copayment fee or other condition on any covered person who  elects  to

purchase  drugs  from  a  network  participating  non-mail  order retail
pharmacy which is not  also  imposed  on  covered  persons  electing  to
purchase  drugs  from  a  network  participating  mail  order  or  other
non-retail  pharmacy;  provided,  however,  that  the provisions of this
section shall  not  supersede  the  terms  of  a  collective  bargaining
agreement  or  apply  to  a  contract that is the result of a collective
bargaining agreement between an employer and a recognized  or  certified
employee organization.
(ll)  Every  small group contract or association group contract issued
by a corporation subject to the provisions of this article that provides
coverage for hospital, medical or surgical expense insurance and is  not
a  grandfathered  health  plan  shall provide coverage for the essential
health benefits package. For purposes of this subsection:
(1) "essential health benefits package" shall  have  the  meaning  set
forth  in  paragraph  three  of  subsection (e) of section four thousand
three hundred six-h of this article;
(2)  "grandfathered  health  plan"  means  coverage  provided   by   a
corporation  in  which an individual was enrolled on March twenty-third,
two thousand ten for as long as  the  coverage  maintains  grandfathered
status in accordance with section 1251(e) of the affordable care act, 42
U.S.C. § 18011(e); and
(3)  "small  group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and
(4) "association group" means a group defined  in  subparagraphs  (B),
(D),  (H), (K), (L) or (M) of paragraph one of subsection (c) of section
four thousand two hundred thirty-five of this chapter, provided that:
(A) the group includes one or more individual members; or
(B) the group includes one or more member employers  or  other  member
groups that are small groups.
(mm)  A corporation shall not be required to offer the contract holder
any benefits that must be made available pursuant  to  this  section  if
such  benefits  must  be  covered  pursuant  to  subsection (kk) of this
section. For any contract issued  within  the  health  benefit  exchange
established  by this state, a corporation shall not be required to offer
the contract holder any benefits that must be made available pursuant to
this section.
(nn) A corporation subject to the provisions of  this  article  or  an
insurance  producer subject to this chapter shall not permit the renewal
of a small group policy which provides  hospital,  surgical  or  medical
expense  coverage  that  renews  on or after January first, two thousand
fourteen, but before July first, two thousand fourteen, so as  to  renew
the  same  policy prior to the policy's annual renewal date for the sole
purpose of evading the requirements  of  the  affordable  care  act  and
regulations  promulgated  thereunder  with  respect  to  such policy. An
isolated, inadvertent renewal date change which was  not  made  for  the
sole  purpose  of  evading  the  requirements of the affordable care act
shall not be deemed a violation of this subsection.
(oo) A medical  expense  indemnity  corporation,  a  hospital  service
corporation  or  a health service corporation 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.
(pp)  No  contract  issued by a medical expense indemnity corporation,
hospital  service  corporation,  or  health  service  corporation   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: (1) the registered nurse
first assistant is certified in operating room nursing; (2) the services
are  within  the  scope  of  practice  of a non-physician surgical first
assistant; and (3) the terms and conditions of  the  contract  otherwise
provide  for  the  coverage  of the services. Nothing in this subsection
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.
* (qq)  Every  medical expense indemnity corporation, hospital service
corporation or health service corporation  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 sb§ (qq)'s
* (qq) Whenever in this section a corporation is required  to  provide
benefits with no coinsurance or deductible, the requirement only applies
with respect to participating providers in the corporation's network, or
with respect to non-participating providers, if the corporation 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  covered  person  pursuant  to
subsection (d) of section four thousand  three  hundred  six-c  of  this
article,  or as applicable, pursuant to paragraph (a) of subdivision six
of section forty-four hundred three of the public health law.
* NB There are 2 sb§ (qq)'s
(rr) Health care forensic examinations performed pursuant  to  section
twenty-eight  hundred  five-i of the public health law covered under the
contract shall not be subject to annual deductibles or coinsurance.
(ss)(1) Every policy which provides  hospital,  surgical,  or  medical
coverage and which offers maternity care coverage pursuant to subsection
(c)  of  this  section shall also provide coverage for abortion services
for an enrollee.
(2) 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.
(3)   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:
(A) The WHO Model Lists of Essential Medicines;
(B) The WHO Abortion Care Guidance; or
(C)  The  National  Academies  of  Science,  Engineering, and Medicine
Consensus Study Report.
(4) Notwithstanding any other provision, a group policy that  provides
hospital,  surgical, or medical expense coverage delivered or issued for
delivery in this state to a religious employer, as defined in  paragraph
five  of  subsection  (cc)  of  this  section,  may exclude coverage for
abortion only if the insurer:
(A) obtains an annual certification from the group policy holder  that
the  policy  holder  is  a  religious  employer  and  that the religious
employer requests a contract without coverage for abortion;
(B) issues a rider to each certificate holder  at  no  premium  to  be
charged  to  the certificate holder or religious employer for the rider,
that provides coverage for abortions subject to the same rules as  would
have been applied to the same category of treatment in the policy issued
to  the  religious  employer.  The rider shall clearly and conspicuously
specify  that  the  religious  employer  does  not  administer  abortion
benefits,  but  that  the  insurer  is  issuing  a rider for coverage of
abortion, and  shall  provide  the  insurer's  contact  information  for
questions; and
(C)  provides  notice  of  the issuance of the policy and rider to the
superintendent in a form and manner acceptable to the superintendent.
* (tt)  Every  contract  issued  by  a   medical   expense   indemnity
corporation, hospital service corporation, or health service corporation
that   provides  coverage  for  a  prescription  drug  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  prescription  drugs  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
subsection 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 sb (tt)'s
* (tt)  Every  large  group  contract  issued  by  a hospital services
corporation or a health services  corporation  which  provides  medical,
major medical, or comprehensive-type coverage shall include coverage for
the  cost  of  pre-exposure prophylaxis (PrEP) for the prevention of HIV
and post-exposure prophylaxis to prevent HIV  infection.  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 contract, unless the
pre-exposure  prophylaxis  (PrEP)  or  post-exposure  prophylaxis has in
effect a rating of 'A' or 'B' in  the  current  recommendations  of  the
United States preventive services task force.
* NB There are 2 sb (tt)'s
(uu)  (1)  Every large group contract 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  large  group
contract  which  provides  major  medical  or similar comprehensive-type
coverage shall provide, upon the prescription of a health care  provider
acting  within  the provider's scope of practice pursuant to title eight
of  the  education  law,  coverage  for  colorectal  cancer   preventive
screenings in accordance with the American Cancer Society Guidelines for
colorectal  cancer  screening  of average risk individuals. The coverage
required  by  this  subsection  shall  also  include  coverage  for  all
additional   colorectal   cancer   examinations   and  laboratory  tests
recommended in accordance with the American  Cancer  Society  Guidelines
for  colorectal  cancer screening of average risk individuals, including
an initial colonoscopy or other medical test or procedure for colorectal
cancer screening and a follow-up colonoscopy performed as a result of  a
positive  result on a non-colonoscopy preventive screening test. A large
group contract shall cover colorectal cancer  screenings,  examinations,
and  laboratory  tests  described  in  this subsection upon any contract
issuance or renewal that occurs six months after the date the  guideline
described in this subsection is issued.
(2)  An enrollee shall not be subject to a deductible, coinsurance, or
any  other  cost-sharing  requirements  for  services  consistent   with
paragraph one of this subsection received from participating providers.