2023 New York Laws › ISC - Insurance › Article 32 - Insurance Contracts - Life, Accident and Health, Annuities › 3221 - Group or Blanket Accident and Health Insurance Policies; Standard Provisions.

§  3221.  Group  or  blanket  accident  and health insurance policies;
standard provisions. (a) No policy of  group  or  blanket  accident  and
health  insurance shall, except as provided in subsection (d) hereof, be
delivered or issued for delivery in this state  unless  it  contains  in
substance the following provisions or provisions which in the opinion of
the   superintendent   are   more  favorable  to  the  holders  of  such
certificates or not less favorable to the holders of  such  certificates
and   more  favorable  to  policyholders,  provided  however,  that  the
provisions set forth in paragraphs six and thirteen of  this  subsection
shall  not  be  applicable  to  any  such  policy  which  is issued to a
policyholder in accordance with subparagraph (E)  of  paragraph  one  of
subsection  (c) of section four thousand two hundred thirty-five of this
chapter:
(1) (A) No statement made  by  the  person  insured  shall  avoid  the
insurance  or  reduce  benefits thereunder unless contained in a written
instrument signed by the person insured.
(B) All statements contained in any such written instrument  shall  be
deemed representations and not warranties.
(2)  That  no agent has authority to change the policy or waive any of
its provisions and that no change in the policy shall  be  valid  unless
approved  by  an  officer of the insurer and evidenced by endorsement on
the policy, or by amendment to the policy signed by the policyholder and
the insurer.
(3) That all new employees or new members in the classes eligible  for
insurance must be added to such class for which they are eligible.
(4)  That  all  premiums due under the policy shall be remitted by the
employer or employers of the persons insured or by some other designated
person acting on behalf of the association  or  group  insured,  to  the
insurer  on or before the due date thereof, with such period of grace as
may be specified therein.
(5) The conditions under which the insurer may decline  to  renew  the
policy.
(6)  That  the insurer shall issue either to the employer or person in
whose name such policy is issued, for delivery to  each  member  of  the
insured  group,  a certificate setting forth in summary form a statement
of the essential features of the insurance coverage and in substance the
following provisions of this subsection.
(7) The ages,  to  which  the  insurance  provided  therein  shall  be
limited;  and  the ages, for which additional restrictions are placed on
benefits, and the additional restrictions placed on the benefits at such
ages.
(8) That written notice of claim must be given to the  insurer  within
twenty  days after the occurrence or commencement of any loss covered by
the policy. Failure to give notice within such time shall not invalidate
or reduce any claim if it shall be shown not  to  have  been  reasonably
possible  to  give  such notice and that notice was given as soon as was
reasonably possible.
(9) That in the case of claim for loss of time for disability, written
proof of such loss must be furnished to the insurer within  thirty  days
after  the  commencement  of the period for which the insurer is liable,
and that subsequent written proofs of the continuance of such disability
must be furnished to the insurer at such intervals as  the  insurer  may
reasonably  require,  and  that in the case of claim for any other loss,
written proof of such loss must be furnished to the insurer  within  one
hundred twenty days after the date of such loss. Failure to furnish such
proof  within  such  time shall not invalidate or reduce any claim if it
shall be shown not to have been  reasonably  possible  to  furnish  such

proof  within  such  time,  provided such proof was furnished as soon as
reasonably possible.
(10)  That  the  insurer will furnish to the person making claim or to
the policyholder for delivery to such person such forms as  are  usually
furnished  by  it  for  filing  proof  of  loss.  If  such forms are not
furnished before the  expiration  of  fifteen  days  after  the  insurer
receives  notice  of  any claim under the policy, the person making such
claim shall be deemed to have complied  with  the  requirements  of  the
policy  as to proof of loss upon submitting within the time fixed in the
policy for filing proof of loss, written proof covering the  occurrence,
character and extent of the loss for which claim is made.
(11)  That the insurer shall have the right and opportunity to examine
the person of the individual for whom claim is made when and so often as
it may reasonably require during the pendency of claim under the  policy
and  also  the right and opportunity to make an autopsy in case of death
where it is not prohibited by law.
(12) That benefits payable under the policy other  than  benefits  for
loss  of  time will be payable not more than sixty days after receipt of
proof, and that, subject to due  proof  of  loss  all  accrued  benefits
payable  under  the  policy  for  loss  of  time  will  be paid not less
frequently than monthly during the continuance of the period  for  which
the  insurer  is  liable,  and  that any balance remaining unpaid at the
termination of such period will be paid immediately upon receipt of such
proof.
(13) That indemnity for loss of life of  the  insured  is  payable  in
accordance  with  subsection  (e)  of  section four thousand two hundred
thirty-five of this chapter; and  that  all  other  indemnities  of  the
policy  are  payable to the insured, except as may be otherwise provided
in accordance with  such  subsection;  and  that  if  a  beneficiary  is
designated,  the  consent  of  the beneficiary shall not be requisite to
change of beneficiary,  or  to  any  other  changes  in  the  policy  or
certificate, except as may be specifically provided by the policy.
(14) That no action at law or in equity shall be brought to recover on
the policy prior to the expiration of sixty days after proof of loss has
been filed in accordance with the requirements of the policy and that no
such action shall be brought after the expiration of two years following
the time such proof of loss is required by the policy.
(15)  Any policy and certificate, other than one issued in fulfillment
of the continuing care responsibilities of an operator of  a  continuing
care  retirement  community  in accordance with article forty-six of the
public health law, made available because of residence in  a  particular
facility,  housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF
A CONTINUING CARE RETIREMENT CONTRACT.  AVAILABILITY  OF  THIS  COVERAGE
WILL  NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT
COMMUNITY."
(16) No policy delivered or issued for delivery in  this  state  which
provides  coverage  for  prescription  drugs and for which cost-sharing,
deductibles or co-insurance obligations are determined  by  category  of
prescription   drugs   shall   impose   cost-sharing,   deductibles   or
co-insurance obligations for any  prescription  drug  that  exceeds  the
dollar  amount  of cost-sharing, deductibles or co-insurance obligations
for non-preferred brand drugs or its equivalent (or brand drugs if there
is no non-preferred brand drug category).
* (17) Space shall be provided on any enrollment, renewal  or  initial
online  portal  process  setup forms required of an insured or applicant
for insurance so that the  insured  or  applicant  for  insurance  shall

register  or decline registration in the donate life registry for organ,
eye and tissue donations under this section of the  enrollment,  renewal
or  initial  online portal process setup forms and that the following is
stated on the form in clear and conspicuous type:
"You  must  fill out the following section: Would you like to be added
to the  Donate  Life  Registry?  Check  box  for  'yes'  or  'skip  this
question'."
* NB Effective June 23, 2024
(b)  No  such policy shall be delivered or issued for delivery in this
state unless a schedule of the premium rates  pertaining  to  such  form
shall have been filed with the superintendent.
(c)  Any  portion of any such policy, which purports, by reason of the
circumstances under which a loss is incurred,  to  reduce  any  benefits
promised  thereunder  to  an amount less than that provided for the same
loss occurring under ordinary circumstances, shall be printed,  in  such
policy  and in each certificate issued thereunder, in bold face type and
with greater prominence than any other  portion  of  the  text  of  such
policy  or  certificate; and all other exceptions of the policy shall be
printed in the policy and in the certificate, with the  same  prominence
as  the  benefits  to  which they apply. If any such policy contains any
provision which affects the liability of the  insurer,  on  the  grounds
stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of
section three thousand two hundred sixteen of this  article,  then  such
provision  shall  be contained in the policy and certificate in the form
set forth in such section.
(d) (1) The superintendent may approve any form of certificate  to  be
issued  under  a blanket accident and health insurance policy as defined
in section four thousand two hundred thirty-seven of this chapter, which
omits or modifies any of the provisions hereinbefore  required,  if  the
superintendent  deems  such  omission  or  modification suitable for the
character of such insurance  and  not  unjust  to  the  persons  insured
thereunder.  Certificates  issued  under a policy or contract of student
accident and health insurance as defined in section three  thousand  two
hundred forty of this article shall comply with such section.
(2)  The superintendent may approve any form of group insurance policy
providing disability benefits to be issued pursuant to article  nine  of
the  workers'  compensation  law  which  omits  or  modifies  any of the
provisions hereinbefore required, if such omission  or  modification  is
not  inconsistent  with the provisions of such article nine and he deems
such omission  or  modification  suitable  for  the  character  of  such
insurance and not unjust to the persons insured thereunder.
(3)  The  superintendent  may also approve any form of group insurance
policy  to  be  issued  to  a  social  services  district  pursuant   to
subdivision  two  of  section  three hundred sixty-seven-a of the social
services law, which omits or modifies any of the provisions hereinbefore
required, if he deems such omission or  modification  suitable  for  the
character of such insurance.
(e) (1) A group policy providing hospital, medical or surgical expense
insurance  for  other  than  specific  diseases  or accident only, shall
provide that if the insurance on an employee or member insured under the
group policy ceases because of  termination  of  (A)  employment  or  of
membership  in  the  class  or  classes  eligible for coverage under the
policy or  (B)  the  policy,  for  any  reason  whatsoever,  unless  the
policyholder  has  replaced the group policy with similar and continuous
coverage for the  same  group  whether  insured  or  self-insured,  such
employee  or member who has been insured under the group policy shall be
entitled to have issued to the insured by the insurer  without  evidence
of  insurability  upon application made to the insurer within sixty days

after such termination, and payment of the quarterly, or, at the  option
of  the  employee  or  member, a less frequent premium applicable to the
form and amount of insurance, an individual  policy  of  insurance.  The
insurer may, at its option elect to provide the insurance coverage under
a  group  insurance  policy,  delivered  in  this  state, in lieu of the
issuance of a converted individual policy of insurance. Such  individual
policy,  or group policy, as the case may be is hereafter referred to as
the converted policy. The benefits provided under the  converted  policy
shall  be  those  required by subsection (f) and (g) of this section, in
the event of termination of the converted  group  policy  of  insurance,
each  insured thereunder shall have a right of conversion to a converted
individual policy of insurance.
(2) The insurer shall not be required  to  issue  a  converted  policy
covering  any  person  if such person is covered for similar benefits by
another hospital or surgical or  medical  expense  insurance  policy  or
hospital  or  medical service subscriber contract or medical practice or
other prepayment plan or by any other plan or program or such person  is
eligible  for  similar  benefits, whether or not covered therefor, under
any arrangement of coverage for individuals in a group, other than under
the converted policy, whether  on  an  insured  or  uninsured  basis  or
similar  benefits  are provided for or available to such person pursuant
to any statute; and the benefits provided or available under any of such
sources which together with the benefits provided  under  the  converted
policy   would  result  in  overinsurance  or  duplication  of  benefits
according to standards on file with the superintendent.
(3) The converted policy shall, at  the  option  of  the  employee  or
member,  provide  identical coverage for the dependents of such employee
or member who were covered under the group  policy.  Provided,  however,
that  if the employee or member chooses the option of dependent coverage
then dependents acquired after the permitted time to convert  stated  in
paragraph  one of this subsection shall be added to the converted family
policy in accordance with the provisions of subsection  (c)  of  section
thirty-two   hundred   sixteen  of  this  article  and  any  regulations
promulgated or guidelines issued by the  superintendent.  The  effective
date  of  the  individual's coverage under the converted policy shall be
the date of the termination of  the  individual's  insurance  under  the
group policy as to those persons covered under the group policy.
(4)  If  delivery  of  an  individual  converted  policy is to be made
outside this state, it may be on such form as the insurer  may  then  be
offering  for such conversion in the jurisdiction where such delivery is
to be made.
(5) The conversion provision shall also be available upon the death of
the employee or member, to the surviving spouse with respect to such  of
the  spouse  and  children  as are then covered by the group policy, and
shall be available to a child solely with respect to  himself  upon  his
attaining  the  limiting  age  of  coverage under the group policy while
covered as a dependent thereunder. It shall also be available  upon  the
divorce  or  annulment of the marriage of the employee or member, to the
former spouse of such employee or member.
(6) (A) Each certificate holder shall be given written notice of  such
conversion  privilege  and  its  duration  within fifteen days before or
after the date of termination of group coverage, provided that  if  such
notice  be  given more than fifteen days but less than ninety days after
the date of termination of group coverage,  the  time  allowed  for  the
exercise   of  such  privilege  of  conversion  shall  be  extended  for
forty-five days after the giving of such notice. If such notice  be  not
given  within  ninety  days  after  the  date  of  termination  of group

coverage, the time allowed for the exercise of such conversion privilege
shall expire at the end of such ninety days.
(B) Written notice by the policyholder given to the certificate holder
or  mailed  to  the  certificate holder's last known address, or written
notice by the insurer be sent by first class  mail  to  the  certificate
holder at the last address furnished to the insurer by the policyholder,
shall  be  deemed full compliance with the provisions of this subsection
for the giving of notice.
(C) A group contract issued by an insurer may contain a  provision  to
the  effect  that  notice  of such conversion privilege and its duration
shall be given by the  policyholder  to  each  certificate  holder  upon
termination of his group coverage.
(7)  In  addition  to  the right of conversion herein, the employee or
member insured under the policy shall at his option, as  an  alternative
to  conversion,  be  entitled  to  have his coverage continued under the
group policy in accordance with the conditions and limitations contained
in subsection (m) of this section, and have issued at  the  end  of  the
period  of  continuation  an individual conversion policy subject to the
terms of this subsection. The effective date for the  conversion  policy
shall  be the day following the termination of insurance under the group
policy, or if there is a continuation of coverage, on the day  following
the  end  of  the period of continuation. Notwithstanding the foregoing,
the superintendent may require conversion or continuation  of  insurance
under  conditions  as  set  forth  in  a regulation for insureds under a
policy issued in accordance with subparagraph (E) of  paragraph  one  of
subsection  (c) of section four thousand two hundred thirty-five of this
chapter.
(8) For purposes  of  this  subsection,  the  term  "dependent"  shall
include  a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.
(f) If the group insurance policy insures the employee or  member  for
hospital,  medical  or  surgical  expense  insurance,  or  if  the group
insurance policy insures the employee or member  for  major  medical  or
similar comprehensive-type coverage, then the conversion privilege shall
entitle  the  employee  or  member  to obtain coverage under a converted
policy providing, at the insured's option, coverage under any one of the
plans described in subsection (g) of this section on an expense incurred
basis.
(g) For conversion purposes, an insurer shall offer to the employee or
member a policy at each level of coverage as defined in  subsection  (b)
of  section  three thousand two hundred seventeen-i of this article that
contains the essential health benefits package  described  in  paragraph
three   of   subsection  (e)  of  section  three  thousand  two  hundred
seventeen-i of this article. Provided, however, the superintendent  may,
after giving due consideration to the public interest, approve a request
made  by  an insurer for the insurer to satisfy the requirements of this
subsection and subsections (e) and  (f)  of  this  section  through  the
offering  of  policies  that  comply  with  this  subsection  by another
insurer, corporation  or  health  maintenance  organization  within  the
insurer's  holding company system, as defined in article fifteen of this
chapter.
(h) Every small group policy or association group policy delivered  or
issued  for  delivery in this state that provides coverage for hospital,
medical or surgical expense insurance and is not a grandfathered  health
plan  shall  provide coverage for the essential health benefits package.
For purposes of this subsection:
(1) "essential health benefits package" shall  have  the  meaning  set
forth in paragraph three of subsection (e) of section three thousand two
hundred seventeen-i of this article;
(2)  "grandfathered health plan" means coverage provided by an insurer
in which an individual was enrolled on March twenty-third, two  thousand
ten  for  as  long  as  the  coverage  maintains grandfathered status in
accordance with section 1251(e) of the affordable care act, 42 U.S.C.  §
18011(e);
(3)  "small  group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and
(4) "association group" means a group defined  in  subparagraphs  (B),
(D),  (H), (K), (L) or (M) of paragraph one of subsection (c) of section
four thousand two hundred thirty-five of this chapter, provided that:
(A) the group includes one or more individual members; or
(B) the group includes one or more member employers  or  other  member
groups that are small groups.
(i)  An  insurer  shall  not be required to offer the policyholder any
benefits that must be made available pursuant to  this  section  if  the
benefits must be covered pursuant to subsection (h) of this section. For
any policy issued within the health benefit exchange established by this
state,  an  insurer  shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section.
(j) No policy of group or blanket accident and health insurance  shall
be  issued  as excess coverage for volunteer firefighters over and above
the coverage  provided  for  pursuant  to  the  volunteer  firefighters'
benefit  law unless such excess policy provides for each of the types of
coverages set forth in subdivision one of section five of such law.  Any
excess  policy which does not contain such provisions shall be construed
as if such coverages were embodied therein.
(k) (1) (A) Every group policy delivered or  issued  for  delivery  in
this  state  which  provides coverage for in-patient hospital care shall
provide coverage for home care to residents in this state,  except  that
this provision shall not apply to a policy which covers persons employed
in more than one state or the benefit structure of which was the subject
of collective bargaining affecting persons who are employed in more than
one state. Such home care coverage shall be included at the inception of
all  new  policies and, with respect to all other policies, added at any
anniversary date of the policy subject to evidence of insurability.
(B) Such coverage may be subject to an annual deductible of  not  more
than  fifty  dollars for each person covered under the policy and may be
subject to a coinsurance provision which provides for  coverage  of  not
less  than  seventy-five  percent  of  the  reasonable  charges for such
services.
(C) Home care means the care and treatment of a covered person who  is
under the care of a physician but only if hospitalization or confinement
in  a  nursing  facility  as  defined in subchapter XVIII of the federal
Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
required if home care was not provided, and the plan covering  the  home
health service is established and approved in writing by such physician.
(D)  Home  care  shall  be  provided  by  an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law and  shall  consist  of  one  or  more  of  the
following:
(i)  Part-time  or  intermittent  home  nursing  care  by or under the
supervision of a registered professional nurse (R.N.).
(ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
(iii) Physical, occupational or speech therapy if provided by the home
health service or agency.
(iv)   Medical   supplies,  drugs  and  medications  prescribed  by  a
physician, and laboratory services by or on behalf of a  certified  home
health  agency  or licensed home care services agency to the extent such
items would have been covered under the contract if the  covered  person
had  been  hospitalized  or  confined  in  a skilled nursing facility as
defined in subchapter XVIII of  the  federal  Social  Security  Act,  42
U.S.C. §§ 1395 et seq.
(E)  For  the  purpose  of  determining  the  benefits  for  home care
available to a covered person, each visit by a member  of  a  home  care
team  shall  be  considered  as  one  home  care visit; the contract may
contain a limitation on the number of home care  visits,  but  not  less
than  forty such visits in any calendar year or in any continuous period
of twelve months, for each person covered under the contract; four hours
of home health aide service shall be considered as one home care visit.
(2) (A) Every insurer issuing a group policy delivered or  issued  for
delivery  in  this state which provides coverage for in-patient hospital
care shall include coverage for preadmission tests performed in hospital
facilities prior to scheduled surgery, except that this provision  shall
not  apply  to  a  policy which covers persons employed in more than one
state or the benefit structure of which was the  subject  of  collective
bargaining affecting persons who are employed in more than one state.
(B)  Such  policy  shall  provide  benefits  for  tests  ordered  by a
physician which  are  performed  in  the  out-patient  facilities  of  a
hospital  as  a  planned  preliminary  to admission of the patient as an
in-patient for surgery in the same hospital, provided that:
(i) tests are necessary for and  consistent  with  the  diagnosis  and
treatment of the condition for which surgery is to be performed;
(ii)  reservations  for  a hospital bed and for an operating room were
made prior to the performance of the tests;
(iii) the surgery actually takes  place  within  seven  days  of  such
presurgical tests; and
(iv) the patient is physically present at the hospital for the tests.
(C)   Coverage  for  abortion  shall  include  coverage  of  any  drug
prescribed for the purpose of an abortion, including  both  generic  and
brand  name  drugs,  even if such drug has not been approved by the food
and drug administration for abortion, provided, however, that such  drug
shall  be  a  recognized medication for abortion in one of the following
established reference compendia:
(i) The WHO Model Lists of Essential Medicines;
(ii) The WHO Abortion Care Guidance; or
(iii) The National Academies of  Science,  Engineering,  and  Medicine
Consensus Study Report.
(3)  Every group policy delivered or issued for delivery in this state
which provides coverage  for  in-patient  surgical  care  shall  include
coverage  for  a second surgical opinion by a qualified physician on the
need for surgery, except that this provision shall not apply to a policy
which covers persons employed in more than  one  state  or  the  benefit
structure  of  which  was the subject of collective bargaining affecting
persons who are employed in more than one state.
(4) (A) Every group policy delivered or issued for  delivery  in  this
state  that  provides coverage for inpatient hospital care shall include
coverage for services  to  treat  an  emergency  condition  provided  in
hospital  facilities,  except  that  this provision shall not apply to a
policy which covers persons employed in  more  than  one  state  or  the
benefit  structure  of  which  was  the subject of collective bargaining
affecting persons who are employed in more than  one  state  unless  the

policy  otherwise  provides  coverage for services to treat an emergency
condition provided in hospital facilities:
(i) without the need for any prior authorization determination;
(ii)  regardless  of  whether the health care provider furnishing such
services is a participating provider with respect to such services;
(iii) if the emergency services are provided  by  a  non-participating
provider,  without imposing any administrative requirement or limitation
on  coverage  that  is  more  restrictive  than  the   requirements   or
limitations that apply to emergency services received from participating
providers; and
(iv)  if  the  emergency  services are provided by a non-participating
provider, the cost-sharing requirement  (expressed  as  a  copayment  or
coinsurance)  shall  be  the  same  requirement that would apply if such
services were provided by a participating provider.
(B) Any requirements of section 2719A(b) of the Public Health  Service
Act,  42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the
requirements of this paragraph with respect  to  coverage  of  emergency
services shall be applicable to every policy subject to this paragraph.
(C)  In  this  paragraph,  an "emergency condition" means a medical or
behavioral  condition  that  manifests  itself  by  acute  symptoms   of
sufficient   severity,  including  severe  pain,  such  that  a  prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention  to  result
in (i) placing the health of the person afflicted with such condition in
serious  jeopardy,  or in the case of a behavioral condition placing the
health of such person  or  others  in  serious  jeopardy;  (ii)  serious
impairment  to such person's bodily functions; (iii) serious dysfunction
of any bodily organ or part of such person; (iv)  serious  disfigurement
of  such  person;  or  (v)  a condition described in clause (i), (ii) or
(iii) of section 1867(e)(1)(A) of the Social Security Act.
(D) In this paragraph, "emergency services" means, with respect to  an
emergency  condition:  (i)  a  medical screening examination as required
under section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, which
is within the capability of the  emergency  department  of  a  hospital,
including  ancillary  services  routinely  available  to  the  emergency
department to evaluate such emergency medical condition: and (ii) within
the capabilities of the staff and facilities available at the  hospital,
such  further  medical  examination  and treatment as are required under
section 1867 of  the  Social  Security  Act,  42  U.S.C.  §  1395dd,  to
stabilize the patient.
(E)  In  this  paragraph,  "to  stabilize"  means,  with respect to an
emergency condition, to provide such medical treatment of the  condition
as  may  be  necessary to assure, within reasonable medical probability,
that no material deterioration of the condition is likely to result from
or occur during the transfer of  the  insured  from  a  facility  or  to
deliver a newborn child (including the placenta).
(5)  (A)  (i)  Every  group  or blanket policy delivered or issued for
delivery in this state which  provides  hospital,  surgical  or  medical
coverage  shall include coverage for maternity care, including hospital,
surgical or medical care to the same extent that  coverage  is  provided
for  illness  or disease under the policy. Such maternity care coverage,
other than coverage for perinatal complications, shall include inpatient
hospital coverage for mother and newborn for at least forty-eight  hours
after  childbirth  for  any delivery other than a caesarean section, and
for at least ninety-six hours after a caesarean section.  Such  coverage
for  maternity  care  shall  include  the services of a midwife licensed
pursuant to article one hundred forty of the education  law,  practicing
consistent  with  section  sixty-nine hundred fifty-one of the education

law and affiliated or practicing in conjunction with a facility licensed
pursuant to article twenty-eight  of  the  public  health  law,  but  no
insurer  shall  be  required  to  pay  for  duplicative routine services
actually provided by both a licensed midwife and a physician.
(ii)  Maternity  care  coverage shall also include, at minimum, parent
education, assistance and training in breast or bottle feeding, and  the
performance of any necessary maternal and newborn clinical assessments.
(iii)  The  mother shall have the option to be discharged earlier than
the time periods established in item (i) of this subparagraph.  In  such
case,  the  inpatient  hospital  coverage must include at least one home
care visit which shall be in addition to, rather than in  lieu  of,  any
home  health  care  coverage available under the policy. The policy must
cover the home care visit, which may be requested  at  any  time  within
forty-eight  hours of the time of delivery (ninety-six hours in the case
of caesarean section), and shall be delivered within twenty-four  hours,
(I)  after  discharge,  or  (II)  of  the  time of the mother's request,
whichever is later. Such home care coverage shall  be  pursuant  to  the
policy  and  subject  to  the  provisions  of this subparagraph, and not
subject to deductibles, coinsurance or copayments.
(B) Coverage provided under this  paragraph  for  care  and  treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.
(6)  (A)  Every  group  policy issued or delivered in this state which
provides coverage for hospital  care  shall  not  exclude  coverage  for
hospital  care  for  diagnosis  and  treatment  of  correctable  medical
conditions otherwise covered by the policy solely  because  the  medical
condition results in infertility; provided, however that:
(i)  subject  to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical  or  medical  procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
(ii)  provided,  further  however,  that  subject to the provisions of
subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage
exclude  diagnostic  tests  and  procedures  provided  as  part  of such
hospital care that are necessary to determine infertility  or  that  are
necessary  in  connection  with  any  surgical  or medical treatments or
prescription  drug  coverage  provided  pursuant  to   this   paragraph,
including  such  diagnostic tests and procedures as hysterosalpingogram,
hysteroscopy, endometrial biopsy,  laparoscopy,  sono-hysterogram,  post
coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
and
(iii)  provided,  further  however,  every  such policy which provides
coverage for prescription drugs shall  include,  within  such  coverage,
coverage  for  prescription  drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility  in
accordance with subparagraph (C) of this paragraph.
(B)  Every  group  policy  issued  or  delivered  in  this state which
provides coverage for  surgical  and  medical  care  shall  not  exclude
coverage  for  surgical  and medical care for diagnosis and treatment of
correctable medical conditions otherwise covered by  the  policy  solely
because  the medical condition results in infertility; provided, however
that:
(i) subject to the provisions of subparagraph (C) of  this  paragraph,
in  no  case  shall such coverage exclude surgical or medical procedures
which would correct malformation, disease or  dysfunction  resulting  in
infertility; and
(ii)  provided,  further  however,  that  subject to the provisions of
subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage
exclude  diagnostic tests and procedures that are necessary to determine
infertility or that are necessary in connection  with  any  surgical  or
medical  treatments  or  prescription drug coverage provided pursuant to
this paragraph,  including  such  diagnostic  tests  and  procedures  as
hysterosalpingogram,   hysteroscopy,  endometrial  biopsy,  laparoscopy,
sono-hysterogram, post coital  tests,  testis  biopsy,  semen  analysis,
blood tests and ultrasound; and
(iii)  provided,  further  however,  every  such policy which provides
coverage for prescription drugs shall  include,  within  such  coverage,
coverage  for  prescription  drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility  in
accordance with subparagraph (C) of this paragraph.
(C)   Coverage  of  diagnostic  and  treatment  procedures,  including
prescription drugs, used in the diagnosis and treatment  of  infertility
as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.
(i) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this subparagraph.
(ii)  Coverage  may  be  subject  to  co-payments,   coinsurance   and
deductibles  as  may  be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a  given
policy.
(iii) Except as provided in items (vi) and (vii) of this subparagraph,
coverage shall not be required to include the diagnosis and treatment of
infertility  in  connection  with:  (I)  in  vitro fertilization, gamete
intrafallopian tube transfers or zygote intrafallopian  tube  transfers;
(II)   the   reversal  of  elective  sterilizations;  (III)  sex  change
procedures; (IV)  cloning;  or  (V)  medical  or  surgical  services  or
procedures  that  are  deemed  to  be  experimental  in  accordance with
clinical guidelines referenced in item (iv) of this subparagraph.
(iv) The superintendent, in  consultation  with  the  commissioner  of
health,   shall   promulgate   regulations  which  shall  stipulate  the
guidelines and standards  which  shall  be  used  in  carrying  out  the
provisions of this subparagraph, which shall include:
(I)  The  identification of experimental procedures and treatments not
covered for the diagnosis and treatment  of  infertility  determined  in
accordance  with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
(II) The identification of the required training, experience and other
standards for health care providers for the provision of procedures  and
treatments  for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted  by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine; and
(III)  The  determination  of  appropriate  medical  candidates by the
treating physician in  accordance  with  the  standards  and  guidelines
established  and  adopted  by  the American College of Obstetricians and
Gynecologists and/or the American Society for Reproductive Medicine.
(v)(I) For the purposes  of  this  paragraph,  "infertility"  means  a
disease  or  condition  characterized  by  the  incapacity to impregnate
another person or to conceive, defined by the  failure  to  establish  a
clinical  pregnancy  after  twelve months of regular, unprotected sexual
intercourse or therapeutic donor insemination, or after  six  months  of
regular,   unprotected   sexual   intercourse   or   therapeutic   donor

insemination for a female thirty-five years of  age  or  older.  Earlier
evaluation  and  treatment  may  be  warranted  based on an individual's
medical history or physical findings.
(II) For purposes of this paragraph, "iatrogenic infertility" means an
impairment  of  fertility  by  surgery, radiation, chemotherapy or other
medical treatment affecting reproductive organs or processes.
(vi) Coverage  shall  also  include  standard  fertility  preservation
services  when  a  medical  treatment  may  directly or indirectly cause
iatrogenic infertility to an insured. Coverage may be subject to  annual
deductibles  and  coinsurance,  including  copayments,  as may be deemed
appropriate by the superintendent  and  as  are  consistent  with  those
established for other benefits within a given policy.
(vii)  Every  large  group  policy delivered or issued for delivery in
this  state  that   provides   medical,   major   medical   or   similar
comprehensive-type  coverage  shall provide coverage for three cycles of
in-vitro fertilization used in the treatment  of  infertility.  Coverage
may   be  subject  to  annual  deductibles  and  coinsurance,  including
copayments, as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
policy. For purposes of this item, a "cycle" is defined  as  either  all
treatment that starts when: preparatory medications are administered for
ovarian  stimulation  for oocyte retrieval with the intent of undergoing
in-vitro fertilization using a fresh embryo transfer; or medications are
administered for endometrial preparation with the intent  of  undergoing
in-vitro fertilization using a frozen embryo transfer.
(viii)  No  insurer  providing  coverage  under  this  paragraph shall
discriminate based on an insured's expected length of life,  present  of
predicted disability, degree of medical dependency, perceived quality of
life, or other health conditions, nor based on personal characteristics,
including  age,  sex,  sexual  orientation,  marital  status  or  gender
identity.
(D) Every policy that provides  coverage  for  prescription  fertility
drugs and requires or permits prescription drugs to be purchased through
a  network  participating  mail order or other non-retail pharmacy shall
provide the same coverage for prescription  fertility  drugs  when  such
drugs  are  purchased from a network participating non-mail order retail
pharmacy provided that the network participating non-mail  order  retail
pharmacy  agrees  in advance through a contractual network agreement, to
the same reimbursement amount, as well as the same applicable terms  and
conditions, that the insurer has established for a network participating
mail  order or other non-retail pharmacy. In such case, the policy shall
not impose  any  fee,  co-payment,  co-insurance,  deductible  or  other
condition  on  any  covered  person  who elects to purchase prescription
fertility drugs through a network participating  non-mail  order  retail
pharmacy  that  it  does  not impose on any covered person who purchases
prescription fertility drugs through a network participating mail  order
or  other non-retail pharmacy; provided, however, that the provisions of
this section shall not supersede the terms of  a  collective  bargaining
agreement  or  apply  to  a  policy  that  is the result of a collective
bargaining agreement between an employer and a recognized  or  certified
employee organization.
(7)(A)  Every  group  or  blanket accident and health insurance policy
issued or issued for delivery  in  this  state  which  provides  medical
coverage  that includes coverage for physician services in a physician's
office  and  every  policy  which  provides  major  medical  or  similar
comprehensive-type  coverage  shall  include  coverage for the following
equipment and supplies for the treatment of diabetes, if recommended  or
prescribed by a physician or other licensed health care provider legally

authorized  to  prescribe  under title eight of the education law: blood
glucose monitors and blood glucose monitors for the  visually  impaired,
data  management  systems,  test  strips for glucose monitors and visual
reading  and  urine  testing strips, insulin, injection aids, cartridges
for the visually impaired, syringes,  insulin  pumps  and  appurtenances
thereto, insulin infusion devices, and oral agents for controlling blood
sugar.  In  addition, the commissioner of the department of health shall
provide and  periodically  update  by  rule  or  regulation  a  list  of
additional diabetes equipment and related supplies such as are medically
necessary  for  the treatment of diabetes, for which there shall also be
coverage.  Such  policies  shall  also  include  coverage  for  diabetes
self-management  education  to  ensure  that  persons  with diabetes are
educated as  to  the  proper  self-management  and  treatment  of  their
diabetic condition, including information on proper diets. Such coverage
for  self-management  education  and education relating to diet shall be
limited to visits medically necessary upon the  diagnosis  of  diabetes,
where  a  physician  diagnoses  a  significant  change  in the patient's
symptoms  or  conditions  which  necessitate  changes  in  a   patient's
self-management,   or   where  reeducation  or  refresher  education  is
necessary. Such education may be provided  by  the  physician  or  other
licensed  health  care  provider  legally  authorized to prescribe under
title eight of the education law, or their staff, as part of  an  office
visit  for  diabetes  diagnosis or treatment, or by a certified diabetes
nurse  educator,  certified   nutritionist,   certified   dietitian   or
registered  dietitian upon the referral of a physician or other licensed
health care provider legally authorized to prescribe under  title  eight
of the education law. Education provided by the certified diabetes nurse
educator,  certified  nutritionist,  certified  dietitian  or registered
dietitian  may  be  limited  to  group  settings  wherever  practicable.
Coverage  for  self-management  education and education relating to diet
shall also include home visits when medically necessary.
* (B)  Such  coverage  may  be  subject  to  annual  deductibles   and
coinsurance  as  may  be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a  given
policy;  provided  however,  the  total  amount that a covered person is
required to pay out of pocket for  covered  prescription  insulin  drugs
shall  be  capped  at  an  amount  not to exceed one hundred dollars per
thirty-day supply, regardless of the amount or type of insulin needed to
fill such covered person's prescription and regardless of the  insured's
deductible,   copayment,   coinsurance   or   any   other  cost  sharing
requirement.
* NB Effective until January 1, 2025
* (B)  Such  coverage  may  be  subject  to  annual  deductibles   and
coinsurance  as  may  be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a  given
policy; provided, however, that covered prescription insulin drugs shall
not be subject to a deductible, copayment, coinsurance or any other cost
sharing requirement.
* NB Effective January 1, 2025
(C)  This  paragraph  shall not apply to a policy which covers persons
employed in more than one state or the benefit structure  of  which  was
the  subject of collective bargaining affecting persons employed in more
than one state unless such policy is issued under  the  New  York  state
health  insurance  plan  established  under  article eleven of the civil
service law or issued to or through a local government.
(8) (A) Every group or blanket policy delivered or issued for delivery
in this state which provides coverage for inpatient hospital care  shall
provide  such coverage for such period as is determined by the attending

physician in consultation with the patient to be  medically  appropriate
for  such  covered  person  undergoing  a  lymph  node  dissection  or a
lumpectomy for the treatment of breast cancer or a mastectomy covered by
the  policy.  Such  coverage  may  be  subject to annual deductibles and
coinsurance as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
policy. Written notice of the availability of  such  coverage  shall  be
delivered  to  the  policyholder  prior  to inception of such policy and
annually thereafter.
(B) An  insurer  providing  coverage  under  this  paragraph  and  any
participating  entity  through  which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy  or  vary  the
terms  of  the  policy  for  the  purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under  this
paragraph;
(iii)  penalize  in  any  way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv) provide incentives (monetary  or  otherwise)  to  a  health  care
practitioner   relating  to  the  services  provided  pursuant  to  this
paragraph intended to  induce  or  have  the  effect  of  inducing  such
practitioner   to   provide  care  to  a  covered  person  in  a  manner
inconsistent with this paragraph; or
(v) restrict coverage for any portion of a period  within  a  hospital
length  of  stay  required  under  this  paragraph  in a manner which is
inconsistent with the coverage provided for  any  preceding  portion  of
such stay.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition  to  the  provisions  of  sections  three  thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to  suspend,  supersede,
amend or otherwise modify such sections.
(9)(A)  Every policy which provides medical, major medical, or similar
comprehensive-type coverage must provide coverage for a  second  medical
opinion  by  an  appropriate  specialist, including but not limited to a
specialist affiliated with a specialty care center for the treatment  of
cancer,  in the event of a positive or negative diagnosis of cancer or a
recurrence of cancer or a recommendation of a course  of  treatment  for
cancer, subject to the following:
(i)  In  the  case  of  a  policy that requires, or provides financial
incentives for, the insured to receive covered services from health care
providers participating in a provider network  maintained  by  or  under
contract  with  the  insurer,  the  policy  shall include coverage for a
second medical opinion from a  non-participating  specialist,  including
but  not limited to a specialist affiliated with a specialty care center
for the treatment of cancer, when the  attending  physician  provides  a
written  referral  to  a  non-participating specialist, at no additional
cost to the insured  beyond  what  such  insured  would  have  paid  for
services  from a participating appropriate specialist. Provided, however
that nothing herein shall impair an insured's rights (if any) under  the
policy  to  obtain  the  second medical opinion from a non-participating
specialist without  a  written  referral,  subject  to  the  payment  of
additional  coinsurance  (if  any)  required  by the policy for services
provided by non-participating providers. The  insurer  shall  compensate

the  non-participating specialist at the usual, customary and reasonable
rate, or at a rate listed on a fee schedule filed and  approved  by  the
superintendent which provides a comparable level of reimbursement.
(ii)  In  the  case  of  a  policy  that  does  not  provide financial
incentives for, and does not require, the  insured  to  receive  covered
services  from health care providers participating in a provider network
maintained by or under contract  with  the  insurer,  the  policy  shall
include  coverage  for  a second medical opinion from a specialist at no
additional cost to the insured beyond what the insured would  have  paid
for comparable services covered under the policy.
(iii)   Such  coverage  may  be  subject  to  annual  deductibles  and
coinsurance as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
policy, and, where applicable, consistent with the provisions of clauses
(i) and (ii) of this subparagraph.
Nothing in this paragraph shall eliminate  or  diminish  an  insurer's
obligation  to comply with the provisions of section four thousand eight
hundred four of this chapter where applicable.  Written  notice  of  the
availability  of  such  coverage  shall be delivered to the policyholder
prior to the inception of such policy and annually thereafter.
(B) An  insurer  providing  coverage  under  this  paragraph  and  any
participating  entity  through  which  an insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy  or  vary  the
terms  of  the  policy  for  the  purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under  this
paragraph;
(iii)  penalize  in  any  way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph; or
(iv) provide incentives (monetary  or  otherwise)  to  a  health  care
practitioner   relating  to  the  coverage  provided  pursuant  to  this
paragraph intended to  induce  or  have  the  effect  of  inducing  such
practitioner   to   provide  care  to  a  covered  person  in  a  manner
inconsistent with this paragraph.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the  provisions  of  sections  three  thousand  two  hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing  in  this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(10) (A) Every  group  or  blanket  policy  delivered  or  issued  for
delivery in this state which provides medical, major medical, or similar
comprehensive-type  coverage  shall  provide  the following coverage for
breast or chest  wall  reconstruction  surgery  after  a  mastectomy  or
partial mastectomy:
(i)  all stages of reconstruction of the breast or chest wall on which
the mastectomy or partial mastectomy has been performed; and
(ii) surgery and reconstruction of the other breast or chest  wall  to
produce a symmetrical appearance;
in  the  manner determined by the attending physician and the patient to
be  appropriate.  Chest  wall  reconstruction  surgery   shall   include
aesthetic  flat  closure  as such term is defined by the National Cancer
Institute. Such coverage  may  be  subject  to  annual  deductibles  and
coinsurance   provisions   as   may   be   deemed   appropriate  by  the
superintendent and as are consistent with those  established  for  other

benefits  within  a  given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to  inception
of such policy and annually thereafter.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll  or  to  renew coverage under the terms of the policy or vary the
terms of the policy for the purpose  or  with  the  effect  of  avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph; or
(v)  restrict  coverage  for any portion of a period within a hospital
length of stay required under  this  paragraph  in  a  manner  which  is
inconsistent  with  the  coverage  provided for any preceding portion of
such stay.
(C) The prohibitions in this paragraph shall be  in  addition  to  the
provisions  of  sections three thousand two hundred thirty-one and three
thousand two hundred thirty-two of this  article  and  nothing  in  this
paragraph  shall  be construed to suspend, supersede, amend or otherwise
modify such sections.
* (11) Every policy that  provides  coverage  for  prescription  drugs
shall  include  coverage  for the cost of enteral formulas for home use,
whether administered orally or via tube feeding, for which  a  physician
or  other  licensed health care provider legally authorized to prescribe
under title eight of the education law has issued a written order.  Such
written  order shall state that the enteral formula is clearly medically
necessary and has been proven effective as a disease-specific  treatment
regimen. Specific diseases and disorders for which enteral formulas have
been  proven  effective shall include, but are not limited to, inherited
diseases of amino-acid or  organic  acid  metabolism;  Crohn's  Disease;
gastroesophageal  reflux; disorders of gastrointestinal motility such as
chronic  intestinal  pseudo-obstruction;  and  multiple,   severe   food
allergies   including,   but   not   limited  to  immunoglobulin  E  and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders  and
impaired  absorption  of  nutrients  caused  by  disorders affecting the
absorptive   surface,   function,   length,   and   motility   of    the
gastrointestinal  tract.  Enteral  formulas that are medically necessary
and taken under written order from a  physician  for  the  treatment  of
specific  diseases  shall  be distinguished from nutritional supplements
taken electively. Coverage for certain inherited diseases of amino  acid
and   organic  acid  metabolism  as  well  as  severe  protein  allergic
conditions shall include modified  solid  food  products  that  are  low
protein,  contain  modified  protein,  or  are amino acid based that are
medically necessary.
* NB There are 2 par (11)'s
* (11)(A) Every policy which is a "managed care product" as defined in
subparagraph (D) of this paragraph that includes coverage for  physician

services  in  a physician's office, and every policy which is a "managed
care product" that provides major medical or similar  comprehensive-type
coverage  shall  include  coverage  for chiropractic care, as defined in
section  six  thousand  five  hundred  fifty-one  of  the education law,
provided by a doctor of chiropractic licensed pursuant  to  article  one
hundred  thirty-two  of  the  education  law,  in  connection  with  the
detection or correction by manual  or  mechanical  means  of  structural
imbalance,  distortion  or subluxation in the human body for the purpose
of removing nerve interference, and  the  effects  thereof,  where  such
interference  is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column.  However,  chiropractic  care
and  services  may  be  subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits,  and  reasonable
utilization  review,  provided that any such amounts, limits and review:
(a) shall not function to direct treatment in  a  manner  discriminative
against  chiropractic  care, and (b) individually and collectively shall
be no more restrictive than those applicable under the  same  policy  to
care   or  services  provided  by  other  health  professionals  in  the
diagnosis, treatment and management of the same or  similar  conditions,
injuries,   complaints,   disorders   or  ailments,  even  if  differing
nomenclature is used  to  describe  the  condition,  injury,  complaint,
disorder  or  ailment.  Nothing  herein  contained shall be construed as
impeding or preventing either the provision or coverage of  chiropractic
care  and  services by duly licensed doctors of chiropractic, within the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.
(C) Every policy which includes coverage for physician services  in  a
physician's  office,  and  every  policy which provides major medical or
similar comprehensive-type coverage, other than a "managed care product"
as defined in subparagraph (D) of this paragraph, shall provide coverage
for chiropractic care, as defined in section six thousand  five  hundred
fifty-one  of  the  education  law, provided by a doctor of chiropractic
licensed pursuant to article one hundred  thirty-two  of  the  education
law,  in  connection  with  the  detection  or  correction  by manual or
mechanical means of structural imbalance, distortion or  subluxation  in
the  human  body for the purpose of removing nerve interference, and the
effects thereof, where such interference is the result of or related  to
distortion,  misalignment  or subluxation of or in the vertebral column.
However, chiropractic care and services may  be  subject  to  reasonable
deductible,  co-payment  and  co-insurance  amounts,  reasonable  fee or
benefit limits, and reasonable utilization  review,  provided  that  any
such  amounts,  limits  and  review:  (a)  shall  not function to direct
treatment in a manner discriminative against chiropractic care, and  (b)
individually  and  collectively  shall be no more restrictive that those
applicable under the same policy to care or services provided  by  other
health  professionals  in the diagnosis, treatment and management of the
same or similar conditions, injuries, complaints, disorders or ailments,
even if differing  nomenclature  is  used  to  describe  the  condition,
injury,  complaint,  disorder or ailment. Nothing herein contained shall
be construed as impeding or preventing either the provision or  coverage
of   chiropractic   care  and  services  by  duly  licensed  doctors  of
chiropractic, within the  lawful  scope  of  chiropractic  practice,  in
hospital facilities on a staff or employee basis.
(D)  For  purposes  of  this paragraph, a "managed care product" shall
mean a policy which requires that medical or other health care  services
covered  under  the  policy,  other  than  emergency  care  services, be
provided by, or pursuant to a referral from, a  primary  care  provider,
and  that services provided pursuant to such a referral be rendered by a

health  care  provider  participating  in  the  insurer's  managed  care
provider  network.  In  addition, a managed care product shall also mean
the in-network portion of a contract  which  requires  that  medical  or
other  health  care  services  covered  under  the  contract, other than
emergency care services, be provided by, or pursuant to a referral from,
a primary care provider, and that services provided pursuant to  such  a
referral  be  rendered  by  a  health care provider participating in the
insurer's managed care provider network, in order for the insured to  be
entitled to the maximum reimbursement under the contract.
(E)  The  coverage required by this paragraph shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 par (11)'s
(12) No policy of group  or  blanket  accident  and  health  insurance
delivered or issued for delivery in this state shall exclude coverage of
a  health  care service, as defined in paragraph two of such subdivision
(e) of section four thousand nine hundred of this chapter,  rendered  or
proposed  to be rendered to an insured on the basis that such service is
experimental or investigational, is rendered as part of a clinical trial
as defined in subsection (b-2) of section  forty-nine  hundred  of  this
chapter,   or   a   prescribed   pharmaceutical  product  referenced  in
subparagraph  (B)  of  paragraph  two  of  subsection  (e)  of   section
forty-nine hundred of this chapter provided that coverage of the patient
costs  of  such  service  has  been  recommended  for  the insured by an
external appeal agent upon an appeal conducted pursuant to  subparagraph
(B)  of  paragraph  four of subsection (b) of section four thousand nine
hundred fourteen of this chapter.  The  determination  of  the  external
appeal  agent  shall  be  binding  on  the parties. For purposes of this
paragraph, patient costs shall have the same meaning as  such  term  has
for  purposes of subparagraph (B) of paragraph four of subsection (b) of
section four thousand nine hundred fourteen of this  chapter;  provided,
however,  that  coverage  for the services required under this paragraph
shall  be  provided  subject  to  the  terms  and  conditions  generally
applicable to other benefits provided under the policy.
(13) Every group or blanket policy delivered or issued for delivery in
this  state  that  provides  major medical or similar comprehensive-type
coverage  shall  provide  such  coverage  for   bone   mineral   density
measurements  or tests, and if such contract otherwise includes coverage
for prescription drugs, drugs and devices approved by the  federal  food
and  drug administration or generic equivalents as approved substitutes.
In determining appropriate coverage provided by subparagraphs  (A),  (B)
and   (C)   of   this  paragraph,  the  insurer  or  health  maintenance
organization shall adopt standards that  include  the  criteria  of  the
federal  Medicare program and the criteria of the national institutes of
health for the detection of osteoporosis, provided  that  such  coverage
shall be further determined as follows:
(A)  for purposes of subparagraphs (B) and (C) of this paragraph, bone
mineral density measurements or tests, drugs and devices  shall  include
those  covered  under  the  federal Medicare program as well as those in
accordance with the criteria  of  the  national  institutes  of  health,
including,   as   consistent   with  such  criteria,  dual-energy  x-ray
absorptiometry.
(B) for purposes of subparagraphs (A) and (C) of this paragraph,  bone
mineral  density  measurements  or  tests,  drugs  and  devices shall be
covered for individuals meeting the criteria under the federal  Medicare
program  or  the criteria of the national institutes of health; provided
that,  to  the  extent  consistent  with  such   criteria,   individuals
qualifying for coverage shall at a minimum, include individuals:
(i)  previously  diagnosed  as  having osteoporosis or having a family
history of osteoporosis; or
(ii)  with  symptoms  or conditions indicative of the presence, or the
significant risk, of osteoporosis; or
(iii) on a prescribed  drug  regimen  posing  a  significant  risk  of
osteoporosis; or
(iv)  with  lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or
(v) with such age, gender and/or other  physiological  characteristics
which pose a significant risk for osteoporosis.
(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed  appropriate  by  the  superintendent  and as are consistent with
those established for other benefits within a given policy.
(D) In addition to subparagraph (A), (B) or  (C)  of  this  paragraph,
every  group  or  blanket  policy  that  provides  hospital, surgical or
medical care coverage, except for  a  grandfathered  health  plan  under
subparagraph  (E)  of  this  paragraph,  shall  provide coverage for the
following items or services for bone mineral density and  such  coverage
shall not be subject to annual deductibles or coinsurance:
(i)  evidence-based  items  or  services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations  of
the United States preventive services task force; and
(ii)  with  respect  to  women,  such  additional  preventive care and
screenings for bone mineral density not described in item  (i)  of  this
subparagraph  and  as provided for in comprehensive guidelines supported
by the health resources and services administration.
(E) For purposes of this paragraph, "grandfathered health plan"  means
coverage  provided  by an insurer in which an individual was enrolled on
March twenty-third, two  thousand  ten  for  as  long  as  the  coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(14)  No  group  or blanket policy delivered or issued for delivery in
this  state  which  provides   medical,   major   medical   or   similar
comprehensive-type  coverage shall exclude coverage for services covered
under such policy when provided  by  a  comprehensive  care  center  for
eating  disorders  pursuant to article thirty of the mental hygiene law;
provided, however, that reimbursement under  such  policy  for  services
provided  through  such  comprehensive care centers shall, to the extent
possible and practicable, be structured in a manner  to  facilitate  the
individualized,  comprehensive  and  integrated plans of care which such
centers' network of practitioners and providers are required to provide.
(15)(A) No group or blanket managed care health insurance policy  that
provides  coverage  for hospital, medical or surgical care shall provide
that  services  of  a  participating  hospital  will   be   covered   as
out-of-network  services  solely  on  the  basis  that  the  health care
provider admitting or  rendering  services  to  the  insured  is  not  a
participating provider.
(B)  No  group  or  blanket  managed care health insurance policy that
provides coverage for hospital, medical or surgical care  shall  provide
that services of a participating health care provider will be covered as
out-of-network  services  solely  on  the  basis  that  the services are
rendered in a non-participating hospital.
(C) For purposes of this paragraph, a  "health  care  provider"  is  a
health  care  professional licensed, registered or certified pursuant to
title  eight  of  the  education  law  or  a  health  care  professional
comparably licensed, registered or certified by another state.
(D)  For  purposes of this paragraph, a "managed care health insurance
policy" is a policy  that  requires  that  services  be  provided  by  a
provider participating in the insurer's network in order for the insured
to receive the maximum level of reimbursement under the policy.
(16)(A)  Every  group  or  blanket  policy  that includes coverage for
dialysis treatment that requires such services  to  be  provided  by  an
in-network   provider   and   that   does   not   provide  coverage  for
out-of-network dialysis  treatment  shall  not  deny  coverage  of  such
services   because  the  services  are  provided  by  an  out-of-network
provider, provided that each of the following conditions are met:
(i) The out-of-network provider  is  duly  licensed  to  practice  and
authorized to provide such treatment;
(ii)  The  out-of-network provider is located outside the service area
of the insurer;
(iii) The in-network healthcare provider treating the insured for  the
condition  issues a written order for dialysis treatment stating that in
his or her opinion such treatment is necessary;
(iv) The insured has notified, in writing, the insurer at least thirty
days in advance of the proposed date or  dates  of  such  out-of-network
dialysis  treatment. The notice shall include the authorization required
by clause (iii) of this subparagraph. In  the  event  the  insured  must
travel on sudden notice due to family or other emergency, shorter notice
may  be  permitted, provided that the insurer has reasonable opportunity
to review the travel and treatment plans of the insured;
(v) The insurer shall have  the  right  to  pre-approve  the  dialysis
treatment and schedule; and
(vi)  Such  coverage  is limited to no greater than ten out-of-network
treatments in a calendar year.
(B) Where coverage for out-of-network dialysis treatment  is  provided
pursuant  to  subparagraph  (A)  of  this paragraph, no insurer shall be
obligated to reimburse the out-of-network provider at an amount  greater
than  it  would  have  paid  for  the  same  treatment within a network,
including all drugs and ancillary services tied to  dialysis  treatment,
and  any amount charged by a provider in excess of the amount reimbursed
by the insurer shall be the responsibility of the insured receiving  the
out-of-network services.
(C)  Such  coverage  of  out-of-network  dialysis services required by
subparagraph (A) of this paragraph shall otherwise  be  subject  to  the
limitations,  exclusions  and  terms  of  the policy, including, but not
limited to, utilization  review,  annual  deductibles,  copayments,  and
coinsurance,  consistent  with those required for other similar benefits
under the policy.
(17) Notwithstanding title  eleven  of  article  five  of  the  social
services  law  or  any  other  law  to  the contrary, every policy which
provides coverage for prescription drugs shall, with regard to eye  drop
medication  requiring  a  prescription  that  has  been  approved by the
insurer  for  coverage,  allow  for  the  limited   refilling   of   the
prescription prior to the last day of the approved dosage period without
regard  to  any  coverage  restrictions  on  early  refill  of renewals.
Provided, however, that any refill dispensed prior to the expiration  of
the  prescribed and approved coverage period pursuant to this paragraph,
shall, to the extent practicable, be limited in quantity so  as  not  to
exceed  the  remaining dosage initially approved for coverage. Provided,
further, that  such  limited  refilling  shall  not  limit  or  restrict
coverage   with  regard  to  any  previously  or  subsequently  approved
prescription for eye drop medication and shall be subject to  the  terms
and  conditions  of  the  policy  otherwise applicable to this coverage.

Provided,  further,  that  a  pharmacist  may  contact  the  prescribing
physician or health care provider to verity the prescription.
(18)  Every  group  or  blanket  policy  which provides medical, major
medical or similar comprehensive-type coverage  that  includes  coverage
for a physical or well care visit once in every three hundred sixty-five
days  shall be interpreted to mean that such physical or well care visit
can be had once every calendar year, regardless  of  whether  or  not  a
period  of  three  hundred sixty-five days has passed since the previous
physical or well care visit.
(19) Every group or  blanket  accident  and  health  insurance  policy
delivered  or  issued  for  delivery in this state that provides medical
coverage that includes coverage for physician services in a  physician's
office   and  every  policy  that  provides  major  medical  or  similar
comprehensive-type coverage shall include  coverage  for  equipment  and
supplies  used  for  the  treatment  of  ostomies,  if  prescribed  by a
physician or other licensed health care provider legally  authorized  to
prescribe under title eight of the education law. Such coverage shall be
subject  to  annual deductibles and coinsurance as deemed appropriate by
the superintendent. The coverage required by  this  paragraph  shall  be
identical to, and shall not enhance or increase the coverage required as
part  of  essential  health  benefits  as  defined  in subsection (a) of
section three thousand two hundred seventeen-i of this article.
(20) No group or blanket policy delivered or issued  for  delivery  in
this  state that provides reimbursement for non-physician surgical first
assistant services when the services are  provided  by  a  non-physician
surgical  first  assistant shall exclude such coverage on the basis that
the non-physician surgical first assistant services were performed by  a
registered nurse first assistant provided that: (A) the registered nurse
first assistant is certified in operating room nursing; (B) the services
are  within  the  scope  of  practice  of a non-physician surgical first
assistant; and (C) the terms and  conditions  of  the  policy  otherwise
provide  for  the  coverage  of  the services. Nothing in this paragraph
shall be construed to prevent  the  medical  management  or  utilization
review  of the services or prevent a policy from requiring that services
are to be provided through a network of participating providers who meet
certain   requirements    for    participation,    including    provider
credentialing.
(21) Every group or blanket policy delivered or issued for delivery in
this  state  that  provides coverage for prescription drugs subject to a
copayment shall charge a copayment for a limited initial prescription of
an opioid drug, which is prescribed in accordance with paragraph (b)  of
subdivision  five  of  section  thirty-three  hundred  one of the public
health law, that is either (i) proportional between the copayment for  a
thirty-day supply and the amount of drugs the patient was prescribed; or
(ii)  equivalent  to  the  copayment for a full thirty-day supply of the
opioid drug, provided that no additional copayments may be  charged  for
any additional prescriptions for the remainder of the thirty-day supply.
(22)  (A)  Every  policy which provides hospital, surgical, or medical
coverage and which offers maternity care coverage pursuant to  paragraph
five  of  this  subsection  shall  also  provide  coverage  for abortion
services for an enrollee.
(B) Coverage for abortion shall not be subject to  annual  deductibles
or  coinsurance,  including  co-payments,  unless  the  policy is a high
deductible health plan as defined in section 223(c)(2) of  the  internal
revenue code of 1986, in which case coverage for abortion may be subject
to the plan's annual deductible.
(C)  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 item one
of subparagraph (E) of paragraph  sixteen  of  subsection  (l)  of  this
section, may exclude coverage for abortion only if the insurer:
(i)  obtains  an annual certification from the group policyholder that
the policyholder is a religious employer and that the religious employer
requests a policy without coverage for abortion;
(ii) 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 abortion 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
(iii)  provides  notice of the issuance of the policy and rider to the
superintendent in a form and manner acceptable to the superintendent.
(l) (1) Every insurer delivering a group policy  or  issuing  a  group
policy  for delivery in this state which provides coverage supplementing
part A and part B of subchapter XVIII of  the  federal  Social  Security
Act,  42 U.S.C. §§ 1395 et seq, must make available and, if requested by
the policyholder, provide coverage  of  supplemental  home  care  visits
beyond  those  provided  by  part A and part B, sufficient to produce an
aggregate coverage of three hundred  sixty-five  home  care  visits  per
policy  year.  Such  coverage  shall be provided pursuant to regulations
prescribed by the superintendent. Written notice of the availability  of
such  coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except  that  this  notice
shall  not  be  required  where  a  policy  covers  two  hundred or more
employees or where the benefit structure was the subject  of  collective
bargaining affecting persons who are employed in more than one state.
(2)  (A)  Every  insurer  delivering a group policy or issuing a group
policy  for  delivery,  in  this  state,  which  provides  coverage  for
in-patient  hospital  care  must make available, and if requested by the
policyholder, provide coverage for  care  in  a  nursing  home.  Written
notice  of  the  availability of such coverage shall be delivered to the
policyholder prior to  inception  of  such  group  policy  and  annually
thereafter, except that this notice shall not be required where a policy
covers  two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are  employed
in more than one state.
(B)  Such coverage shall be made available at the inception of all new
policies and, with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.
(C) In this paragraph, care in a nursing home means the continued care
and treatment of a covered person who is under the care of  a  physician
but only if:
(i)  the  care  is  provided  in  a nursing home as defined in section
twenty-eight hundred one of the public health law or a  skilled  nursing
facility  as  defined in subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq;
(ii) the covered person has been in a hospital for at least three days
immediately preceding admittance to the  nursing  home  or  the  skilled
nursing facility; and
(iii) further hospitalization would otherwise be necessary.
(D)  In  determining  the total days of coverage for nursing home care
the aggregate of the number of covered days of care in  a  hospital  and
the  number  of covered days of care in a nursing home, with two days of

care in a nursing home equivalent to one day of care in a hospital, need
not exceed the number of covered days of hospital  care  provided  under
the contract in a benefit period.
(E) The level of benefits to be provided for nursing home care must be
reasonably related to the benefits provided for hospital care.
(3)  (A)  Every  insurer  delivering a group policy or issuing a group
policy  for  delivery,  in  this  state,  which  provides  coverage  for
in-patient  hospital  care  must  make available and if requested by the
policyholder provide coverage to residents in this state for  ambulatory
care  in  hospital  out-patient  facilities, as a hospital is defined in
section twenty-eight hundred one of the public health law, or subchapter
XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq,  and
physicians' offices. Written notice of the availability of such coverage
shall  be delivered to the policyholder prior to inception of such group
policy and annually thereafter, except that this  notice  shall  not  be
required  where  a  policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
(B) In this paragraph:
(i)  "Ambulatory  care  in  hospital  out-patient  facilities"   means
services    for   diagnostic   X-rays,   laboratory   and   pathological
examinations, physical and occupational therapy and  radiation  therapy,
and   services   and   medications   used   for  nonexperimental  cancer
chemotherapy and cancer hormone therapy, provided that such services and
medications are related to and necessary for the treatment or  diagnosis
of  the  patient's illness or injury, are ordered by a physician and, in
the case of physical therapy services, are to be furnished in connection
with the same illness for which the patient had been hospitalized or  in
connection  with  surgical  care,  but  in  no  event  need benefits for
physical therapy be provided which commences more than six months  after
discharge from a hospital or the date surgical care was rendered, and in
no  event  need  benefits  for  physical therapy be provided after three
hundred sixty-five days from the date of discharge from  a  hospital  or
the date surgical care was rendered.
(ii) "Ambulatory  care  in  physicians'  offices"  means  services for
diagnostic  X-rays,  radiation  therapy,  laboratory  and   pathological
examinations,  and  services  and  medications  used for nonexperimental
cancer chemotherapy and  cancer  hormone  therapy,  provided  that  such
services  and medications are related to and necessary for the treatment
or diagnosis of the patient's  illness  or  injury,  and  ordered  by  a
physician.
(C)  Such coverage shall be made available at the inception of all new
policies and, with respect to  policies  issued  before  January  first,
nineteen  hundred  eighty-three,  at  the  first annual anniversary date
thereafter, without evidence  of  insurability  and  at  any  subsequent
annual anniversary date subject to evidence of insurability.
(4)  (A)  Every  insurer  delivering a group policy or issuing a group
policy for delivery, in this  state,  that  provides  reimbursement  for
psychiatric or psychological services or for the diagnosis and treatment
of  mental  health  conditions,  however  defined  in  such  policy,  by
physicians, psychiatrists  or  psychologists,  shall  provide  the  same
coverage  to  insureds  for  such  services when performed by a licensed
clinical social worker, within the lawful scope of his or her  practice,
who  is  licensed  pursuant  to  article  one  hundred fifty-four of the
education  law  and  mental  health  counselors,  marriage  and   family
therapists,  and psychoanalysts licensed pursuant to article one hundred
sixty-three of the education law, within the lawful scope of his or  her
practice.    Nothing  herein  shall be construed to modify or expand the

scope of practice of a mental  health  counselor,  marriage  and  family
therapist,  or  psychoanalyst  licensed  pursuant to article one hundred
sixty-three of the education  law.  Further,  nothing  herein  shall  be
construed to create a new mandated health benefit.
(B)  The  state  board  for  social  work shall maintain a list of all
licensed clinical social workers qualified for reimbursement under  this
paragraph.
(C)  Such coverage shall be made available at the inception of all new
policies and, with respect to  all  other  policies  at  any  subsequent
annual   anniversary   date   of  the  policy  subject  to  evidence  of
insurability.
(E) The state board for social work  shall  maintain  a  list  of  all
licensed  clinical  social  workers  qualified  for  reimbursement under
subparagraph (D) of this paragraph.
(5) (A) Every insurer delivering a group or school blanket  policy  or
issuing  a  group  or school blanket policy for delivery, in this state,
which provides coverage for inpatient  hospital  care  or  coverage  for
physician   services  shall  provide  coverage  for  the  diagnosis  and
treatment of mental health conditions and:
* (i) where the policy provides coverage for inpatient hospital  care,
benefits  for inpatient care in a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law and  benefits  for  outpatient
care  provided  in  a  facility  issued  an operating certificate by the
commissioner of mental health pursuant  to  the  provisions  of  article
thirty-one  of  the mental hygiene law, or in a facility operated by the
office of mental health or in a  crisis  stabilization  center  licensed
pursuant  to  section  36.01  of  the  mental  hygiene  law or, for care
provided in other states, to similarly licensed or  certified  hospitals
or facilities; and
* NB  Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the  commissioner  of
health have promulgated regulations
* (i)  where the policy provides coverage for inpatient hospital care,
benefits for: inpatient care in a hospital as defined by subdivision ten
of section  1.03  of  the  mental  hygiene  law;  sub-acute  care  in  a
residential  facility  licensed  or  operated  by  the  office of mental
health; outpatient care provided  by  a  facility  issued  an  operating
certificate  by  the  commissioner  of  mental  health  pursuant  to the
provisions of article thirty-one of the mental  hygiene  law,  or  by  a
facility  operated  by  the  office  of  mental  health; outpatient care
provided by a crisis stabilization center licensed pursuant  to  section
36.01  of  the  mental hygiene law; outpatient care provided by a mobile
crisis intervention services provider licensed, certified, or designated
by the office of mental health or the office of addiction  services  and
supports;  outpatient  and inpatient care for critical time intervention
services and outpatient care for assertive community treatment  services
provided   by   facilities   issued  an  operating  certificate  by  the
commissioner of mental health pursuant  to  the  provisions  of  article
thirty-one  of  the  mental  hygiene law, beginning no later than thirty
days following discharge from a hospital as defined by  subdivision  ten
of section 1.03 of the mental hygiene law or the emergency department of
a  hospital  licensed  pursuant  to  article  twenty-eight of the public
health law; or, for care provided in other states, to similarly licensed
or certified hospitals, facilities, or licensed, certified or designated
providers; and
* NB Effective January 1, 2025 but shall not take effect  until  after
the  superintendent of financial services and the commissioner of health
have promulgated regulations
(ii) where the policy provides coverage  for  physician  services,  it
shall include 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  a  professional  corporation  or university faculty practice
corporation thereof. Nothing herein shall  be  construed  to  modify  or
expand  the scope of practice of a mental health counselor, marriage and
family therapist, or psychoanalyst  licensed  pursuant  to  article  one
hundred  sixty-three of the education law. Further, nothing herein shall
be construed to create a new mandated health benefit.
(B) Coverage required by this  paragraph  may  be  subject  to  annual
deductibles, co-pays and coinsurance as may be deemed appropriate by the
superintendent  and  shall  be  consistent  with  those imposed on other
benefits under the policy. Provided that  no  copayment  or  coinsurance
imposed  for  outpatient  mental  health services provided in a facility
licensed, certified or otherwise authorized  by  the  office  of  mental
health  shall exceed the copayments or coinsurance imposed for a primary
care office visit under the policy.
(C)  Coverage  under  this  paragraph  shall   not   apply   financial
requirements or treatment limitations to mental health benefits that are
more   restrictive  than  the  predominant  financial  requirements  and
treatment limitations applied to substantially all medical and  surgical
benefits covered by the policy.
(D) The criteria for medical necessity determinations under the policy
with  respect  to  mental health benefits shall be made available by the
insurer to any insured, prospective insured, or in-network provider upon
request.
(E) For purposes of this paragraph:
(i) "financial requirement" means deductible, copayments,  coinsurance
and out-of-pocket expenses;
(ii)  "predominant"  means  that  a financial requirement or treatment
limitation is the most common or frequent  of  such  type  of  limit  or
requirement;
* (iii)  "treatment  limitation"  means  limits  on  the  frequency of
treatment, number of visits, days of coverage, or other  similar  limits
on  the  scope  or  duration  of  treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting  or
excluding  benefits  based on medical necessity, or based on whether the
treatment is  experimental  or  investigational;  formulary  design  for
prescription   drugs;   network  tier  design;  standards  for  provider
admission to participate in a network,  including  reimbursement  rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first or step therapy protocols; exclusions  based  on  failure  to
complete  a  course  of  treatment; and restrictions based on geographic
location, facility type, provider specialty,  and  other  criteria  that
limit  the scope or duration of benefits for services provided under the
policy; and
* NB Effective until January 1, 2025 and shall remain in effect  until
after  the  superintendent of financial services and the commissioner of
health have promulgated regulations
* (iii) "treatment  limitation"  means  limits  on  the  frequency  of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or

excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy;
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (iv)  "mental  health condition" means any mental health disorder as
defined in the most recent edition of  the  diagnostic  and  statistical
manual  of  mental  disorders  or  the  most  recent  edition of another
generally recognized independent standard of  current  medical  practice
such as the international classification of diseases.
* NB  Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the  commissioner  of
health have promulgated regulations
* (iv)  "mental  health condition" means any mental health disorder as
defined in the most recent edition of  the  diagnostic  and  statistical
manual  of  mental  disorders  or  the  most  recent  edition of another
generally recognized independent standard of  current  medical  practice
such as the international classification of diseases;
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (v)  "assertive  community treatment services" means a comprehensive
and  integrated   combination   of   treatment,   rehabilitation,   case
management,  and  support  services  primarily  provided in an insured's
residence or other community locations  by  a  mobile  multidisciplinary
mental  health treatment team licensed pursuant to article thirty-one of
the mental hygiene law;
* NB Effective January 1, 2025 but shall not take effect  until  after
the  superintendent of financial services and the commissioner of health
have promulgated regulations
* (vi) "critical time intervention services" means  services  rendered
by  a  provider  licensed under article thirty-one of the mental hygiene
law that provides evidence-based, therapeutic interventions that include
intensive outreach, engagement, and care coordination services that  are
provided  to  an insured before the insured is discharged from inpatient
care in a hospital as defined by subdivision ten of section 1.03 of  the
mental  hygiene  law  or the emergency department of a hospital licensed
pursuant to article twenty-eight of the public health law  and  continue
after discharge until the insured is stabilized; and
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
* (vii)  "residential  facility" means crisis residence facilities and
community residences for eating disorder integrated  treatment  programs
licensed pursuant to article thirty-one of the mental hygiene law.
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
(F)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici

Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
(G)  This  subparagraph  shall apply to hospitals and crisis residence
facilities in this state that are licensed or operated by the office  of
mental  health that are participating in the insurer's provider network.
Where the policy provides coverage for inpatient hospital care, benefits
for inpatient hospital care in a hospital as defined by subdivision  ten
of  section  1.03  of  the mental hygiene law and benefits for sub-acute
care in a crisis residence facility licensed or operated by  the  office
of  mental  health  shall  not  be subject to preauthorization. Coverage
provided under this subparagraph shall also not be subject to concurrent
utilization review for individuals who have  not  attained  the  age  of
eighteen  during  the  first  fourteen  days of the inpatient admission,
provided the facility notifies the insurer of both the admission and the
initial treatment plan  within  two  business  days  of  the  admission,
performs  daily  clinical  review  of  the  insured, and participates in
periodic consultation with the insurer to ensure that  the  facility  is
using  the  evidence-based  and  peer  reviewed clinical review criteria
utilized by the insurer which is approved by the office of mental health
and appropriate to the age of the insured to ensure that  the  inpatient
care  is  medically  necessary for the insured. For individuals who have
attained age eighteen, coverage provided under this  subparagraph  shall
also not be subject to concurrent review during the first thirty days of
the  inpatient  or residential admission, provided the facility notifies
the insurer of both the admission and the initial treatment plan  within
two  business  days  of the admission, performs daily clinical review of
the insured, and participates in periodic consultation with the  insurer
to  ensure  that  the  facility  is  using  the  evidence-based and peer
reviewed clinical review criteria  utilized  by  the  insurer  which  is
approved  by  the  office of mental health and appropriate to the age of
the insured, to  ensure  that  the  inpatient  or  residential  care  is
medically  necessary  for the insured. However, concurrent review may be
performed during the first thirty days  if  an  insured  meets  clinical
criteria  designated by the office of mental health or where the insured
is admitted to a hospital or facility which has been designated  by  the
office  of mental health for concurrent review, in consultation with the
commissioner of health and the superintendent.  All  treatment  provided
under  this  subparagraph may be reviewed retrospectively. Where care is
denied  retrospectively,  an  insured  shall  not  have  any   financial
obligation  to  the  facility  for any treatment under this subparagraph
other than any copayment, coinsurance, or deductible otherwise  required
under the policy.
(H)  This  subparagraph shall apply to crisis stabilization centers in
this state that are licensed pursuant to section  36.01  of  the  mental
hygiene  law and participate in the insurer's provider network. Benefits
for care by a crisis  stabilization  center  shall  not  be  subject  to
preauthorization.  All treatment provided under this subparagraph may be
reviewed retrospectively.  Where  care  is  denied  retrospectively,  an
insured  shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.
* (I) This subparagraph shall  apply  to  mobile  crisis  intervention
services  providers  licensed, certified, or designated by the office of
mental health or the office of  addiction  services  and  supports.  For
purposes  of  this  subparagraph,  "mobile crisis intervention services"
means mental health and substance use disorder services, consisting  of:
(1) telephonic crisis triage and response; (2) mobile crisis response to
provide  intervention  and  facilitate access to other behavioral health

services; and (3) mobile and telephonic  follow-up  services  after  the
initial  crisis  response until the insured is stabilized provided to an
insured who is experiencing, or is at imminent risk of  experiencing,  a
behavioral  health  crisis, which includes instances in which an insured
cannot manage their  primarily  psychiatric  or  substance  use  related
symptoms   without   de-escalation   or   intervention.   Mobile  crisis
intervention services do not include services  provided  to  an  insured
after the insured has been stabilized.
(i)  Benefits  for  covered  services  provided  by  a  mobile  crisis
intervention services provider shall not be subject to preauthorization.
Except where otherwise required by law,  nothing  in  this  subparagraph
shall  prevent  services  provided subsequent to the provision of mobile
crisis intervention services from being subject to preauthorization.
(ii) Benefits  for  covered  services  provided  by  a  mobile  crisis
intervention  services  provider  shall be covered regardless of whether
the mobile crisis intervention  services  provider  is  a  participating
provider.
(iii)  If  the  covered  services  are provided by a non-participating
mobile crisis intervention  services  provider,  an  insurer  shall  not
impose  any administrative requirement or limitation on coverage that is
more restrictive than the requirements  or  limitations  that  apply  to
covered   services   received   from   a   participating  mobile  crisis
intervention services provider.
(iv) If the covered  services  are  provided  by  a  non-participating
mobile  crisis  intervention services provider, the insured's copayment,
coinsurance, and deductible shall be the same as  would  apply  if  such
covered   services  were  provided  by  a  participating  mobile  crisis
intervention services provider.
(v) A mobile crisis intervention services provider reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against, an insured for the services provided  pursuant  to
this  subparagraph,  except for the collection of in-network copayments,
coinsurance, or deductibles for which the  insured  is  responsible  for
under the terms of the policy.
* NB  Effective  January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of  health
have promulgated regulations
(J)  This  subparagraph  shall  apply  to  school-based  mental health
clinics that are licensed pursuant to article thirty-one of  the  mental
hygiene  law  and  provide outpatient care in pre-school, elementary, or
secondary schools. An insurer shall provide  reimbursement  for  covered
outpatient care when provided by such school-based mental health clinics
at  a pre-school, elementary, or secondary school, regardless of whether
the school-based mental health clinic  furnishing  such  services  is  a
participating  provider with respect to such services. Reimbursement for
such covered services shall  be  at  the  rate  negotiated  between  the
insurer  and  school-based  mental health clinic or, in the absence of a
negotiated rate, an amount no less than the rate that would be paid  for
such  services  pursuant  to  the medical assistance program under title
eleven of article five of the social services law. Payment by an insurer
pursuant to this section shall be  payment  in  full  for  the  services
provided.  The  school-based mental health clinic reimbursed pursuant to
this section shall not charge or seek any reimbursement from or have any
recourse against, an insured for the services provided pursuant to  this
subparagraph,  except  for  the  collection  of  in-network  copayments,
coinsurance, or deductibles for which the  insured  is  responsible  for
under the terms of the policy.
* (K)  This  subparagraph shall apply to outpatient treatment provided
in a facility issued an operating certificate  by  the  commissioner  of
mental  health  pursuant  to the provisions of article thirty-one of the
mental hygiene law, or in a facility operated by the  office  of  mental
health, or in a crisis stabilization center licensed pursuant to section
36.01  of the mental hygiene law, that is participating in the insurer's
provider  network.  Reimbursement  for  covered   outpatient   treatment
provided  by  such  a  facility shall be at rates negotiated between the
insurer and the participating facility, provided that such rates are not
less than the rates that would be paid for such  treatment  pursuant  to
the medical assistance program under title eleven of article five of the
social  services  law.  For the purposes of this subparagraph, the rates
that would be paid for such treatment pursuant to the medical assistance
program under title eleven of article five of the  social  services  law
shall  be  the  rates  with  an  effective  date  of  April first of the
preceding year, which shall be established prior to October first of the
preceding calendar year. Prior to the submission of premium rate filings
and  applications,  the  superintendent  shall  provide  insurers   with
guidance  on  factors  to  consider  in  calculating  the impact of rate
changes  for  the  purposes  of  submitting  premium  rate  filings  and
applications  to  the  superintendent for the subsequent policy year. To
the extent that the rates with an effective date of April  first  differ
from  the  estimated  rates  incorporated  in  premium  rate filings and
applications, insurers  may  account  for  such  differences  in  future
premium  rate  filings  and applications submitted to the superintendent
for approval.
* NB Effective January 1, 2025
(6) (A) Every policy that provides hospital, major medical or  similar
comprehensive   coverage   shall  provide  inpatient  coverage  for  the
diagnosis  and  treatment   of   substance   use   disorder,   including
detoxification  and  rehabilitation  services.  Such  inpatient coverage
shall include unlimited medically necessary treatment for substance  use
disorder  treatment  services provided in residential settings. Further,
such inpatient  coverage  shall  not  apply  financial  requirements  or
treatment  limitations,  including  utilization  review requirements, to
inpatient substance use disorder benefits that are more restrictive than
the predominant financial requirements and treatment limitations applied
to substantially all  medical  and  surgical  benefits  covered  by  the
policy.
(B)   Coverage  provided  under  this  paragraph  may  be  limited  to
facilities in New York state that are licensed, certified  or  otherwise
authorized by the office of alcoholism and substance abuse services and,
in  other  states, to those which are accredited by the joint commission
as alcoholism, substance abuse or chemical dependence treatment programs
and are similarly licensed, certified, or otherwise  authorized  in  the
state in which the facility is located.
(C)  Coverage  provided  under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other  benefits  within  a
given policy.
(D) This subparagraph shall apply to facilities in this state that are
licensed,  certified or otherwise authorized by the office of alcoholism
and substance abuse services that are  participating  in  the  insurer's
provider  network.  Coverage  provided under this paragraph shall not be
subject to preauthorization.  Coverage  provided  under  this  paragraph
shall  also  not  be subject to concurrent utilization review during the
first twenty-eight days of the inpatient  admission  provided  that  the
facility  notifies  the  insurer  of  both the admission and the initial

treatment plan within two business days of the admission.  The  facility
shall  perform  daily clinical review of the patient, including periodic
consultation with the insurer at or just prior to the fourteenth day  of
treatment  to  ensure  that the facility is using the evidence-based and
peer reviewed clinical review tool utilized  by  the  insurer  which  is
designated  by the office of alcoholism and substance abuse services and
appropriate to the age of the patient,  to  ensure  that  the  inpatient
treatment  is  medically  necessary for the patient. Prior to discharge,
the facility shall provide the patient and the insurer  with  a  written
discharge plan which shall describe arrangements for additional services
needed  following  discharge  from  the inpatient facility as determined
using the evidence-based and peer-reviewed clinical review tool utilized
by the insurer which is designated  by  the  office  of  alcoholism  and
substance  abuse  services.  Prior  to  discharge,  the  facility  shall
indicate to the insurer whether services included in the discharge  plan
are  secured  or  determined to be reasonably available. Any utilization
review of treatment provided  under  this  subparagraph  may  include  a
review  of  all  services  provided  during  such  inpatient  treatment,
including all services provided during the first  twenty-eight  days  of
such inpatient treatment. Provided, however, the insurer shall only deny
coverage  for  any  portion  of  the  initial twenty-eight day inpatient
treatment on the basis that such treatment was not  medically  necessary
if  such inpatient treatment was contrary to the evidence-based and peer
reviewed  clinical  review  tool  utilized  by  the  insurer  which   is
designated  by the office of alcoholism and substance abuse services. An
insured shall not have any financial obligation to the facility for  any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.
(E) The criteria for medical necessity determinations under the policy
with  respect to inpatient substance use disorder benefits shall be made
available by  the  insurer  to  any  insured,  prospective  insured,  or
in-network provider upon request.
(F) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement;
(iii)  "treatment  limitation"  means  limits  on  the  frequency   of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy; and
(iv)  "substance use disorder" shall have the meaning set forth in the
most recent edition of the diagnostic and statistical manual  of  mental
disorders  or  the  most  recent edition of another generally recognized
independent  standard  of  current  medical   practice   such   as   the
international classification of diseases.
(G)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
(7)  (A)  Every policy that provides medical, major medical or similar
comprehensive-type coverage shall provide outpatient  coverage  for  the
diagnosis   and   treatment   of   substance   use  disorder,  including
detoxification and rehabilitation  services.  Such  coverage  shall  not
apply  financial  requirements  or  treatment  limitations to outpatient
substance use disorder benefits  that  are  more  restrictive  than  the
predominant  financial requirements and treatment limitations applied to
substantially all medical and surgical benefits covered by the policy.
(B) Coverage under this paragraph may be limited to facilities in this
state that are licensed, certified or otherwise authorized by the office
of addiction services and supports to provide outpatient  substance  use
disorder  services and crisis stabilization centers licensed pursuant to
section 36.01 of the mental hygiene law, and, in other states, to  those
which  are  accredited by the joint commission as alcoholism or chemical
dependence treatment  programs  and  similarly  licensed,  certified  or
otherwise authorized in the state in which the facility is located.
(C)  Coverage  provided  under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other  benefits  within  a
given policy.
(C-1) A large group policy that provides coverage under this paragraph
shall  not impose copayments or coinsurance for outpatient substance use
disorder services that exceeds the copayment or coinsurance imposed  for
a  primary  care  office  visit.  Provided that no greater than one such
copayment may be imposed for all services provided in a single day by  a
facility  licensed,  certified  or otherwise authorized by the office of
alcoholism and substance abuse services to provide outpatient  substance
use disorder services.
(D)  A  policy  providing coverage for substance use disorder services
pursuant to this paragraph shall provide up to twenty outpatient  visits
per  policy  or  calendar  year  to  an individual who identifies him or
herself as a family member of a  person  suffering  from  substance  use
disorder  and  who  seeks  treatment as a family member who is otherwise
covered by  the  applicable  policy  pursuant  to  this  paragraph.  The
coverage  required by this paragraph shall include treatment as a family
member pursuant to such family member's own policy provided such  family
member:
(i)  does not exceed the allowable number of family visits provided by
the applicable policy pursuant to this paragraph; and
(ii) is otherwise entitled to coverage pursuant to this paragraph  and
such family member's applicable policy.
(E) This subparagraph shall apply to facilities in this state that are
licensed,  certified or otherwise authorized by the office of alcoholism
and substance abuse services for the provision of outpatient,  intensive
outpatient,  outpatient  rehabilitation  and  opioid  treatment that are
participating in the insurer's provider network. Coverage provided under
this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
provided  under this paragraph shall not be subject to concurrent review
for the  first  four  weeks  of  continuous  treatment,  not  to  exceed
twenty-eight  visits, provided the facility notifies the insurer of both
the start of  treatment  and  the  initial  treatment  plan  within  two
business  days.  The  facility  shall perform clinical assessment of the
patient at each visit, including periodic consultation with the  insurer
at  or  just prior to the fourteenth day of treatment to ensure that the

facility is using the evidence-based and peer reviewed  clinical  review
tool  utilized  by  the  insurer  which  is  designated by the office of
alcoholism and substance abuse services and appropriate to  the  age  of
the  patient,  to  ensure  that  the  outpatient  treatment is medically
necessary for the patient.  Any  utilization  review  of  the  treatment
provided  under  this  subparagraph may include a review of all services
provided  during  such  outpatient  treatment,  including  all  services
provided  during  the  first  four weeks of continuous treatment, not to
exceed twenty-eight visits,  of  such  outpatient  treatment.  Provided,
however,  the  insurer  shall  only deny coverage for any portion of the
initial four weeks of continuous treatment, not to  exceed  twenty-eight
visits,  for  outpatient  treatment on the basis that such treatment was
not medically necessary if such outpatient treatment was contrary to the
evidence-based and peer reviewed clinical review tool  utilized  by  the
insurer  which  is  designated by the office of alcoholism and substance
abuse services. An insured shall not have any  financial  obligation  to
the  facility  for  any treatment under this subparagraph other than any
copayment, coinsurance,  or  deductible  otherwise  required  under  the
policy.
(F) The criteria for medical necessity determinations under the policy
with respect to outpatient substance use disorder benefits shall be made
available  by  the  insurer  to  any  insured,  prospective  insured, or
in-network provider upon request.
(G) For purposes of this paragraph:
(i) "financial requirement" means deductible, copayments,  coinsurance
and out-of-pocket expenses;
(ii)  "predominant"  means  that  a financial requirement or treatment
limitation is the most common or frequent  of  such  type  of  limit  or
requirement;
(iii)   "treatment  limitation"  means  limits  on  the  frequency  of
treatment, number of visits, days of coverage, or other  similar  limits
on  the  scope  or  duration  of  treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting  or
excluding  benefits  based on medical necessity, or based on whether the
treatment is  experimental  or  investigational;  formulary  design  for
prescription   drugs;   network  tier  design;  standards  for  provider
admission to participate in a network,  including  reimbursement  rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first or step therapy protocols; exclusions  based  on  failure  to
complete  a  course  of  treatment; and restrictions based on geographic
location, facility type, provider specialty,  and  other  criteria  that
limit  the scope or duration of benefits for services provided under the
policy; and
(iv) "substance use disorder" shall have the meaning set forth in  the
most  recent  edition of the diagnostic and statistical manual of mental
disorders or the most recent edition  of  another  generally  recognized
independent   standard   of   current   medical  practice  such  as  the
international classification of diseases.
(H) An insurer shall provide  coverage  under  this  paragraph,  at  a
minimum,  consistent  with  the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity  Act  of  2008  (29  U.S.C.  §
1185a).
(I)  This  subparagraph shall apply to crisis stabilization centers in
this state that are licensed pursuant to section  36.01  of  the  mental
hygiene  law and participate in the insurer's provider network. Benefits
for care in a crisis  stabilization  center  shall  not  be  subject  to
preauthorization.  All treatment provided under this subparagraph may be
reviewed retrospectively.  Where  care  is  denied  retrospectively,  an

insured  shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.
* (J)  This  subparagraph shall apply to facilities in this state that
are licensed, certified,  or  otherwise  authorized  by  the  office  of
addiction  services  and  supports  for  the  provision  of  outpatient,
intensive outpatient, outpatient  rehabilitation  and  opioid  treatment
that  are participating in the insurer's provider network. Reimbursement
for covered outpatient treatment provided by such facilities shall be at
rates negotiated between the insurer  and  the  participating  facility,
provided  that such rates are not less than the rates that would be paid
for such treatment pursuant to  the  medical  assistance  program  under
title  eleven  of  article  five  of  the  social  services law. For the
purposes of this subparagraph, the rates that would  be  paid  for  such
treatment  pursuant to the medical assistance program under title eleven
of article five of the social services law shall be the  rates  with  an
effective  date  of  April  first  of the preceding year, which shall be
established prior to October first of the preceding calendar year. Prior
to  the  submission  of  premium  rate  filings  and  applications,  the
superintendent  shall  provide  insurers  with  guidance  on  factors to
consider in calculating the impact of rate changes for the  purposes  of
submitting  premium  rate filings and applications to the superintendent
for the subsequent policy year. To the extent that  the  rates  with  an
effective   date   of  April  first  differ  from  the  estimated  rates
incorporated in premium rate  filings  and  applications,  insurers  may
account  for  such  differences  in  future  premium  rate  filings  and
applications submitted to the superintendent for approval.
* NB Effective January 1, 2025
(7-a) (A) No policy that provides medical, major  medical  or  similar
comprehensive-type  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 policy,
including federal food and drug administration-approved over-the-counter
opioid overdose reversal  medication  as  prescribed,  dispensed  or  as
otherwise  authorized under state or federal law, except where otherwise
prohibited by law. Every policy 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 or maintenance treatment of
a  substance  use  disorder,  including  all   buprenorphine   products,
methadone,  long  acting injectable naltrexone, or medication for opioid
overdose reversal prescribed or dispensed to an  insured  covered  under
the  policy,  including  federal  food  and drug administration-approved
over-the-counter opioid  overdose  reversal  medication  as  prescribed,
dispensed  or as otherwise authorized under state or federal law, except
where otherwise prohibited by law.
(B)  Coverage  provided  under  this  paragraph  may  be  subject   to
copayments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the policy.
(7-b)  Every  policy that provides coverage for treatment at an opioid
treatment program shall not impose a co-payment fee during the course of
treatment on any insured for such treatment. For the  purposes  of  this
section  "opioid  treatment  program"  means  a  program or practitioner

engaged in opioid  treatment  of  individuals  with  an  opioid  agonist
treatment medication.
(8)  (A)  Every  insurer  issuing  a group policy for delivery in this
state that provides medical, major-medical or similar comprehensive-type
coverage shall provide coverage for  the  provision  of  preventive  and
primary care services.
(B)  In  subparagraphs  (A), (C) and (D) of this paragraph, preventive
and primary care services means the following  services  rendered  to  a
covered  child  of  an  insured  from  the  date  of  birth  through the
attainment of nineteen years of age:
(i) an initial hospital check-up and well-child  visits  scheduled  in
accordance   with  the  prevailing  clinical  standards  of  a  national
association of pediatric physicians designated by  the  commissioner  of
health  (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service  other  than  the
limits  under  state  law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or  under
the  supervision  of  a  physician, or other professional licensed under
article one hundred thirty-nine of the  education  law  whose  scope  of
practice  pursuant  to  such  law  includes the authority to provide the
specified  services.  Coverage  shall  be  provided  for  such  services
rendered  in  a hospital, as defined in section twenty-eight hundred one
of the public health law, or in  an  office  of  a  physician  or  other
professional  licensed  under  article  one  hundred  thirty-nine of the
education law whose scope of practice pursuant to such law includes  the
authority to provide the specified services;
(ii)  at  each  visit,  services  in  accordance  with  the prevailing
clinical standards of such designated association, including  a  medical
history,  a  complete  physical  examination,  developmental assessment,
anticipatory guidance, appropriate immunizations  and  laboratory  tests
which  tests  are  ordered at the time of the visit and performed in the
practitioner's  office,  as  authorized  by  law,  or  in   a   clinical
laboratory; and
(iii)  necessary immunizations, as determined by the superintendent in
consultation with the commissioner of health,  consisting  of  at  least
adequate  dosages  of  vaccine  against  diphtheria, pertussis, tetanus,
polio, measles,  rubella,  mumps,  haemophilus  influenzae  type  b  and
hepatitis  b,  which  meet  the  standards approved by the United States
public health service for such biological products.
(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not be subject to annual deductibles or coinsurance.
(D) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not restrict or eliminate existing coverage provided  by
the policy.
(E)  In  addition  to  subparagraph  (A),  (B),  (C)  or  (D)  of this
paragraph, every  group  policy  that  provides  hospital,  surgical  or
medical  care  coverage,  except  for  a grandfathered health plan under
subparagraph (G) of this  paragraph,  shall  provide  coverage  for  the
following preventive care and screenings for insureds, and such coverage
shall not be subject to annual deductibles or coinsurance:
(i)   evidence-based   items  or  services  for  preventive  care  and
screenings that have in effect a rating of 'A' or  'B'  in  the  current
recommendations of the United States preventive services task force;
(ii)  immunizations  that  have  in  effect  a recommendation from the
advisory committee on immunization practices of the centers for  disease
control and prevention with respect to the individual involved;
(iii)  with  respect  to  children, including infants and adolescents,
evidence-informed  preventive  care  and  screenings  provided  for   in

comprehensive  guidelines supported by the health resources and services
administration; and
(iv)  with  respect  to  women,  such  additional  preventive care and
screenings not described  in  item  (i)  of  this  subparagraph  and  as
provided  for  in  comprehensive  guidelines  supported  by  the  health
resources and services administration.
(F) The requirements of this paragraph shall also be applicable  to  a
blanket  policy  of  hospital,  medical  or  surgical  expense insurance
covering students pursuant to subparagraph (C)  of  paragraph  three  of
subsection (a) of section four thousand two hundred thirty-seven of this
chapter.
(G)  For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was  enrolled  on
March  twenty-third,  two  thousand  ten  for  as  long  as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(9) Every insurer issuing a group policy for delivery  in  this  state
which  policy  provides coverage for any service within the lawful scope
of practice of a duly licensed registered professional nurse, must  make
available,   and   if   requested   by   the  contract  holder,  provide
reimbursement for such service when such service is performed by a  duly
licensed   registered   professional   nurse   provided,  however,  that
reimbursement shall not be made for  nursing  services  provided  to  an
insured  in  a  general  hospital,  nursing home or a facility providing
health  related  services,  as  such  terms  are  defined   in   section
twenty-eight  hundred one of the public health law, or in a facility, as
such term is defined in subdivision six of section 1.03  of  the  mental
hygiene law, or in a physician's office. Such coverage may be subject to
annual  deductibles and co-insurance as may be deemed appropriate by the
superintendent and are consistent with those imposed on  other  benefits
within  a  given  policy.  Such  coverage shall not replace, restrict or
eliminate existing coverage provided by the  policy.  Coverage  for  the
services  of  a  duly  licensed  registered  professional  nurse need be
provided only if the  nature  of  the  patient's  illness  or  condition
requires  nursing  care  which can appropriately be provided by a person
with the education and professional skill of a  registered  professional
nurse  and  the  nursing  care  is  necessary  in  the  treatment of the
patient's illness or condition. Written notice of  the  availability  of
such  coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except  that  this  notice
shall  not  be  required  where  a  policy  covers  two  hundred or more
employees or where the benefit structure was the subject  of  collective
bargaining affecting persons who are employed in more than one state.
(10)  (A)  Every  insurer  issuing a group policy for delivery in this
state which provides coverage for  inpatient  hospital  care  must  make
available  and  if  requested  by  the policyholder provide coverage for
hospice care.  Written notice of the availability of such coverage shall
be delivered to the policyholder prior to inception of such group policy
and annually thereafter, except that this notice shall not  be  required
where a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(B)  For  the  purposes of this paragraph, hospice care shall mean the
care and treatment of a covered person who has been  certified  by  such
person's  primary attending physician as having a life expectancy of six
months or less and which is provided by a hospice organization certified
pursuant to article forty of the public health law or  under  a  similar

certification  process  required  by  the  state  in  which  the hospice
organization is located.
(C)  Hospice  care coverage shall be at least equal to: (i) a total of
two hundred ten days of coverage beginning with the first day  on  which
care  is  provided,  for  inpatient  hospice  care  in a hospice or in a
hospital and home care and outpatient services provided by the  hospice,
including   drugs  and  medical  supplies,  and  (ii)  five  visits  for
bereavement counseling services, either before or  after  the  insured's
death, provided to the family of the terminally ill insured.
(D)  Such coverage shall be made available at the inception of all new
policies and, with respect to policies issued before the effective  date
of  this  provision,  at  the  first annual anniversary date thereafter,
without  evidence  of  insurability  and  at   any   subsequent   annual
anniversary date subject to evidence of insurability.
(E) Such coverage may be subject to annual deductibles and coinsurance
as  may  be  deemed appropriate by the superintendent and are consistent
with those imposed on other benefits within a given policy period.
(11) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for  delivery  in  this  state  that  provides
coverage  for  hospital,  surgical  or  medical  care  shall provide the
following coverage for mammography screening for occult breast cancer:
(i) upon the recommendation of a physician, a mammogram, which may  be
provided  by breast tomosynthesis, at any age for covered persons having
a prior history of breast cancer or who have  a  first  degree  relative
with a prior history of breast cancer;
(ii)  a  single  baseline  mammogram,  which may be provided by breast
tomosynthesis, for covered persons aged thirty-five through thirty-nine,
inclusive;
(iii)  an  annual  mammogram,  which  may  be   provided   by   breast
tomosynthesis, for covered persons aged forty and older; and
(iv)  for  large  group  policies  that provide coverage for hospital,
surgical or medical care, an annual mammogram for covered  persons  aged
thirty-five through thirty-nine, inclusive, upon the recommendation of a
physician,  subject to the insurer's determination that the mammogram is
medically necessary.
(B) Such coverage required pursuant to subparagraph (A) or (C) of this
paragraph shall not be subject to annual deductibles or coinsurance.
(C) For purposes of subparagraphs  (A)  and  (B)  of  this  paragraph,
mammography  screening  means  an  X-ray examination of the breast using
dedicated equipment, including X-ray tube, filter,  compression  device,
screens,  films  and cassettes, with an average glandular radiation dose
less  than  0.5  rem  per  view  per  breast;  provided,  however,  that
mammography screening shall also include breast tomosynthesis.
(D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
every group or blanket  policy  that  provides  coverage  for  hospital,
surgical  or  medical care, except for a grandfathered health plan under
subparagraph (E) of this  paragraph,  shall  provide  coverage  for  the
following mammography screening services, and such coverage shall not be
subject to annual deductibles or coinsurance:
(i)  evidence-based  items  or  services  for mammography that have in
effect a rating of 'A' or 'B' in  the  current  recommendations  of  the
United States preventive services task force; and
(ii)  with  respect  to  women,  such  additional  preventive care and
screenings  for  mammography  not  described  in  item   (i)   of   this
subparagraph  and  as provided for in comprehensive guidelines supported
by the health resources and services administration.
(E) For purposes of this paragraph, "grandfathered health plan"  means
coverage  provided  by an insurer in which an individual was enrolled on

March twenty-third, two  thousand  ten  for  as  long  as  the  coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(F)  Screening  and  diagnostic  imaging  for  the detection of breast
cancer, including diagnostic mammograms, breast ultrasounds, or magnetic
resonance imaging, covered under the policy  shall  not  be  subject  to
annual deductibles or coinsurance.
(11-a) (A) Every policy delivered or issued for delivery in this state
which  provides  medical  coverage  that includes coverage for physician
services in a physician's office and every policy which  provides  major
medical  or  similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized  to  prescribe
under  title  eight  of  the  education  law, the following coverage for
diagnostic screening for prostatic cancer:
(i) standard diagnostic testing  including,  but  not  limited  to,  a
digital  rectal  examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and
(ii) an annual standard  diagnostic  examination  including,  but  not
limited to, a digital rectal examination and a prostate-specific antigen
test  for  men  age  fifty and over who are asymptomatic and for men age
forty and over with  a  family  history  of  prostate  cancer  or  other
prostate cancer risk factors.
(B)  Such  coverage  shall  not  be  subject  to annual deductibles or
coinsurance.
(11-b) (A) Every large group 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 large group policy
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 paragraph 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 policy shall
cover colorectal cancer screenings, examinations, and  laboratory  tests
described  in  this  paragraph  upon any policy issuance or renewal that
occurs six months  after  the  date  the  guideline  described  in  this
paragraph is issued.
(B)  An  insured shall not be subject to a deductible, coinsurance, or
any  other  cost-sharing  requirements  for  services  consistent   with
subparagraph   (A)   of   this  paragraph  received  from  participating
providers.
* (11-c) (A) Every insurer delivering a group  or  blanket  policy  or
issuing  a  group  or  blanket  policy  for  delivery in this state that
provides   coverage   for   medical,   major   medical,    or    similar
comprehensive-type   coverage   shall  provide  coverage  for  biomarker
precision medical testing for the purposes of diagnosis,  treatment,  or
appropriate  management  of,  or  ongoing  monitoring to guide treatment
decisions for, an insured's disease or condition when one or more of the
following recognizes  the  efficacy  and  appropriateness  of  biomarker
precision   medical   testing   for  diagnosis,  treatment,  appropriate

management, or guiding treatment decisions for an insured's  disease  or
condition:
(i)  labeled indications for a test approved or cleared by the federal
food and drug administration or indicated tests  for  a  food  and  drug
administration approved drug;
(ii)  centers  for  medicare  and  medicaid services national coverage
determinations or  medicare  administrative  contractor  local  coverage
determinations;
(iii) nationally recognized clinical practice guidelines; or
(iv)  peer-reviewed  literature  and  peer-reviewed scientific studies
published in or accepted for publication by medical journals  that  meet
nationally  recognized  requirements for scientific manuscripts and that
submit most of their published articles for review by  experts  who  are
not part of the editorial staff.
(B)  Such  coverage  shall  be  provided  in a manner that shall limit
disruptions  in  care  including  the  need  for  multiple  biopsies  or
biospecimen samples.
(C)  As  used  in  this  paragraph, the following terms shall have the
following meanings:
(i)  "Biomarker"  means  a  characteristic  that  is  measured  as  an
indicator  of  normal  biological  processes,  pathogenic  processes, or
responses  to  an  exposure  or  intervention,   including   therapeutic
interventions.
(ii)  "Biomarker  precision  medical  testing" means the analysis of a
patient's tissue, blood, or other biospecimen  for  the  presence  of  a
biomarker.   Biomarker   testing   includes   but   is  not  limited  to
single-analyte  tests  and  multi-plex  panel  tests  performed   at   a
participating   in-network  laboratory  facility  that  is  either  CLIA
certified or CLIA waived by the federal food and drug administration.
(iii)  "Nationally  recognized  clinical  practice  guidelines"  means
evidence-based  clinical  practice  guidelines  informed by a systematic
review of evidence and an assessment  of  the  benefits,  and  risks  of
alternative  care options intended to optimize patient care developed by
independent organizations or medical professional societies utilizing  a
transparent  methodology  and reporting structure and with a conflict of
interest policy.
* NB Effective January 1, 2025
(12) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for delivery  in  this  state  which  provides
coverage   for   prescribed   drugs   approved  by  the  food  and  drug
administration of the United States  government  for  the  treatment  of
certain  types  of cancer shall not exclude coverage of any such drug on
the basis that such drug has been prescribed for the treatment of a type
of cancer for which the drug has not been approved by the food and  drug
administration. Provided, however, that such drug must be recognized for
treatment  of  the  specific  type of cancer for which the drug has been
prescribed in one of the following established reference compendia:
(i)  the  American   Hospital   Formulary   Service-Drug   Information
(AHFS-DI);
(ii)  National  Comprehensive  Cancer  Networks  Drugs  and  Biologics
Compendium;
(iii) Thomson Micromedex DrugDex;
(iv)  Elsevier  Gold  Standard's  Clinical  Pharmacology;   or   other
authoritative compendia as identified by the Federal Secretary of Health
and  Human  Services  or  the  Centers  for Medicare & Medicaid Services
(CMS); or recommended by review article or editorial comment in a  major
peer reviewed professional journal.
(B)  Notwithstanding  the provisions of this paragraph, coverage shall
not be required for any experimental or  investigational  drugs  or  any
drug  which  the  food  and  drug  administration  has  determined to be
contraindicated for treatment of the specific type of cancer  for  which
the  drug  has  been  prescribed. The provisions of this paragraph shall
apply to cancer drugs only and nothing  herein  shall  be  construed  to
create,  impair,  alter,  limit,  modify,  enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any  other  disease  or
condition.
(12-a) (A) Every policy delivered or issued for delivery in this state
that  provides  medical,  major  medical,  or similar comprehensive-type
coverage and provides coverage for prescription drugs and also  provides
coverage  for  cancer  chemotherapy treatment shall provide coverage for
prescribed, orally administered anticancer medications used to  kill  or
slow  the  growth  of  cancerous  cells. Such coverage may be subject to
co-pays,  coinsurance  or  deductibles,  provided  that   the   co-pays,
coinsurance  or  deductibles  are at least as favorable to an insured as
the co-pays, coinsurance or  deductibles  that  apply  to  coverage  for
intravenous or injected anticancer medications.
(B)  An  insurer  providing  coverage  under  this  paragraph  and any
participating entity through which the insurer  offers  health  services
shall not:
(i) vary the terms of the policy for the purpose or with the effect of
avoiding compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person  to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit  the  compensation  of  a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv)  provide  incentives  (monetary  or  otherwise)  to a health care
practitioner  relating  to  the  services  provided  pursuant  to   this
paragraph  intended  to  induce  or  have  the  effect  of inducing such
practitioner  to  provide  care  to  a  covered  person  in   a   manner
inconsistent with this paragraph; or
(v)  achieve compliance with this paragraph by imposing an increase in
cost sharing for an intravenous or injected anticancer medication.
(13) Consistent with federal law  every  insurer  delivering  a  group
policy  or  issuing  a  group  policy  for  delivery in this state which
provides coverage supplementing part A and part B of subchapter XVIII of
the federal Social Security Act, 42 USC §§  1395  et  seq.,  shall  make
available and, if requested by the policyholder, provide coverage for at
least  ninety  days  of  care  in  a  nursing home as defined in section
twenty-eight hundred one of the public health  law,  except  where  such
coverage   would   duplicate   coverage  that  is  available  under  the
aforementioned subchapter XVIII. Such coverage shall be  made  available
at  the  inception  of  all  new policies and, with respect to all other
policies at each anniversary date of the policy.
(A) Coverage shall be subject to a copayment  of  twenty-five  dollars
per day.
(B)  Brochures  describing  such  coverage  must  be  provided  to the
policyholder at the inception of all new policies and thereafter on each
anniversary date of the policy, and with respect to all  other  policies
annually  at each anniversary date of the policy. Such brochures must be
approved by the superintendent in consultation with the commissioner  of
health.
(C)  The  commensurate  rate  for the coverage must be approved by the
superintendent.
(D) Such insurers shall report to the  superintendent  each  year  the
number  of  contract  holders  to  whom  such  insurers have issued such
policies for nursing home coverage and the approximate number of persons
covered by such policies.
(14)  (A)  Every  group  or  blanket  policy  delivered  or issued for
delivery in this state  that  provides  hospital,  surgical  or  medical
coverage   shall  provide  coverage  for  an  annual  cervical  cytology
screening for cervical cancer and its precursor states  for  women  aged
eighteen and older.
(B)  For  purposes  of  subparagraphs  (A)  and (C) of this paragraph,
cervical cytology screening shall include an annual pelvic  examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services  provided  in  connection with examining and evaluating the Pap
smear.
(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.
(D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
every group or  blanket  policy  that  provides  hospital,  surgical  or
medical   coverage,   except  for  a  grandfathered  health  plan  under
subparagraph (E) of this  paragraph,  shall  provide  coverage  for  the
following  cervical cytology screening services, and such coverage shall
not be subject to annual deductibles or coinsurance:
(i) evidence-based items or services for cervical cytology  that  have
in  effect  a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(ii) with respect  to  women,  such  additional  preventive  care  and
screenings  for  cervical  cytology  not  described  in item (i) of this
subparagraph and as provided for in comprehensive  guidelines  supported
by the health resources and services administration.
(E)  For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was  enrolled  on
March  twenty-third,  two  thousand  ten  for  as  long  as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(15)(A) Every group or blanket policy delivered or issued for delivery
in this state which provides major medical or similar comprehensive-type
coverage  shall  include  coverage  for  prehospital  emergency  medical
services  for the treatment of an emergency condition when such services
are provided by an ambulance service issued  a  certificate  to  operate
pursuant to section three thousand five of the public health law.
(B) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any  recourse  against  an insured for the services provided pursuant to
this paragraph, except for the collection of copayments, coinsurance  or
deductibles  for which the insured is responsible for under the terms of
the policy.
* (C) An  insurer  shall  provide  reimbursement  for  those  services
prescribed  by  this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon  rates,  an
insurer  shall  pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.
* NB Effective until January 1, 2025
* (C) An  insurer  shall  provide  reimbursement  for  those  services
prescribed  by  this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon  rates,  an

insurer  shall  pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.  The  insurer  shall  send
such  payments  directly  to the provider of such ambulance services, if
the  ambulance  service  has  on file an executed assignment of benefits
form with the claim.
* NB Effective January 1, 2025
* (D) The provisions of this paragraph shall have  no  application  to
transfers  of patients between hospitals or health care facilities by an
ambulance service as described in subparagraph (A) of this paragraph.
* NB Effective until January 1, 2025
* (D) The provisions of this paragraph shall have  no  application  to
transfers  of patients between hospitals or health care facilities by an
ambulance service as described in subparagraph  (A)  of  this  paragraph
unless such services are covered under the policy.
* NB Effective January 1, 2025
(E) As used in this paragraph:
(i)   "Prehospital   emergency  medical  services"  means  the  prompt
evaluation and treatment  of  an  emergency  medical  condition,  and/or
non-air-borne  transportation  of  the  patient  to a hospital, provided
however,   where   the   patient   utilizes   non-air-borne    emergency
transportation  pursuant to this paragraph, reimbursement shall be based
on whether a prudent  layperson,  possessing  an  average  knowledge  of
medicine  and  health,  could  reasonably  expect  the  absence  of such
transportation to result  in  (I)  placing  the  health  of  the  person
affected  with  such  condition in serious jeopardy, or in the case of a
behavioral condition placing the health of  such  person  or  others  in
serious  jeopardy;  (II)  serious  impairment  to  such  person's bodily
functions; (III) serious dysfunction of any bodily organ or part of such
person; (IV) serious disfigurement of such person; or  (V)  a  condition
described  in  clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
Social Security Act.
(ii) "Emergency condition" means a  medical  or  behavioral  condition
that   manifests  itself  by  acute  symptoms  of  sufficient  severity,
including severe pain, such that  a  prudent  layperson,  possessing  an
average  knowledge  of  medicine and health, could reasonably expect the
absence of immediate medical attention to  result  in  (I)  placing  the
health  of the person afflicted with such condition in serious jeopardy,
or in the case of a behavioral condition  placing  the  health  of  such
person  or  others  in serious jeopardy; (II) serious impairment to such
person's bodily functions; ( (III) serious  dysfunction  of  any  bodily
organ or part of such person; (IV) serious disfigurement of such person;
or  (V)  a  condition  described in clause (i), (ii) or (iii) of section
1867(e)(1)(A) of the Social Security Act.
(16) (A) Every group or blanket policy that  provides  medical,  major
medical, or similar comprehensive type coverage that is issued, amended,
renewed,  effective or delivered on or after January first, two thousand
twenty, shall provide coverage for all of  the  following  services  and
contraceptive methods:
(1) All FDA-approved contraceptive drugs, devices, and other products.
This  includes  all  FDA-approved  over-the-counter contraceptive drugs,
devices, and products as prescribed or  as  otherwise  authorized  under
state or federal law. The following applies to this coverage:
(a)   where   the  FDA  has  approved  one  or  more  therapeutic  and
pharmaceutical  equivalent,  as  defined  by  the  FDA,  versions  of  a
contraceptive drug, device, or product, a group or blanket policy is not
required  to  include all such therapeutic and pharmaceutical equivalent
versions in its formulary, so long as  at  least  one  is  included  and
covered without cost-sharing and in accordance with this paragraph;
(b)  if the covered therapeutic and pharmaceutical equivalent versions
of a drug, device, or product are not available or are deemed  medically
inadvisable  a  group  or  blanket  policy shall provide coverage for an
alternate therapeutic  and  pharmaceutical  equivalent  version  of  the
contraceptive  drug,  device,  or  product  without cost-sharing. If the
attending health care provider, in his or  her  reasonable  professional
judgment,  determines  that  the  use  of  a  non-covered therapeutic or
pharmaceutical equivalent of a drug, device, or  product  is  warranted,
the   health   care   provider's   determination  shall  be  final.  The
superintendent shall  promulgate  regulations  establishing  a  process,
including  timeframes,  for  an  insured,  an  insured's  designee or an
insured's health care provider to  request  coverage  of  a  non-covered
contraceptive drug, device, or product. Such regulations shall include a
requirement that insurers use an exception form that shall meet criteria
established by the superintendent;
(c)  this  coverage  shall  include  emergency  contraception  without
cost-sharing when provided pursuant to a  prescription  or  order  under
section  sixty-eight  hundred  thirty-one  of  the education law or when
lawfully provided over the counter; and
(d) this coverage must allow for the dispensing of up to twelve months
worth of a contraceptive at one time;
(2) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and
identified in the  comprehensive  guidelines  supported  by  the  health
resources  and  services  administration and thereby incorporated in the
essential health benefits benchmark plan;
(3) Patient education and counseling on contraception; and
(4) Follow-up services related to the drugs,  devices,  products,  and
procedures  covered under this paragraph, including, but not limited to,
management of side effects,  counseling  for  continued  adherence,  and
device insertion and removal.
(B)  A  group  or  blanket  policy subject to this paragraph shall not
impose a deductible, coinsurance, copayment, or any  other  cost-sharing
requirement on the coverage provided pursuant to this paragraph.
(C)  Except  as  otherwise authorized under this paragraph, a group or
blanket policy shall not  impose  any  restrictions  or  delays  on  the
coverage required under this paragraph.
(D)  Benefits  for  an enrollee under this paragraph shall be the same
for an  enrollee's  covered  spouse  or  domestic  partner  and  covered
nonspouse dependents.
(E)   Notwithstanding  any  other  provision  of  this  subsection,  a
religious employer may request a contract without coverage  for  federal
food  and  drug  administration  approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so  requested,
such  contract  shall  be  provided  without  coverage for contraceptive
methods.  This paragraph shall not be  construed  to  deny  an  enrollee
coverage of, and timely access to, contraceptive methods.
(1)  For  purposes  of  this  subsection, a "religious employer" is an
entity for which each of the following is true:
(a) The inculcation of religious values is the purpose of the entity.
(b) The entity primarily  employs  persons  who  share  the  religious
tenets of the entity.
(c) The entity serves primarily persons who share the religious tenets
of the entity.
(d)  The  entity  is  a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(2) Every religious employer that invokes the exemption provided under
this paragraph shall provide written  notice  to  prospective  enrollees

prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
(F)  (1)  Where a group policyholder makes an election not to purchase
coverage  for  contraceptive  drugs  or  devices  in   accordance   with
subparagraph  (E) of this paragraph each certificateholder covered under
the policy issued to that group policyholder shall  have  the  right  to
directly  purchase the rider required by this paragraph from the insurer
which issued the group policy at the prevailing  small  group  community
rate  for  such  rider  whether  or  not the employee is part of a small
group.
(2) Where a group policyholder  makes  an  election  not  to  purchase
coverage   for   contraceptive  drugs  or  devices  in  accordance  with
subparagraph (E) of this  paragraph,  the  insurer  that  provides  such
coverage   shall  provide  written  notice  to  certificateholders  upon
enrollment with the insurer of their right to directly purchase a  rider
for  coverage for the cost of contraceptive drugs or devices. The notice
shall also advise the certificateholders of the additional  premium  for
such coverage.
(G)  Nothing  in  this  paragraph  shall be construed as authorizing a
group or blanket policy which provides coverage for  prescription  drugs
to  exclude coverage for prescription drugs prescribed for reasons other
than contraceptive purposes.
(H)  For   the   purposes   of   this   paragraph,   "over-the-counter
contraceptive  products"  shall  mean  those  products  provided  for in
comprehensive guidelines supported by the health resources and  services
administration as of January twenty-first, two thousand nineteen.
(17)  (A)  Every group or blanket accident and health insurance policy
delivered or issued for delivery in this state which  provides  coverage
for  hospital  or  surgical care coverage shall not exclude coverage for
screening, diagnosis  and  treatment  of  medical  conditions  otherwise
covered  by  the policy because the treatment is provided to diagnose or
treat autism spectrum disorder.
(B) Every group or blanket policy that  provides  physician  services,
medical,  major  medical  or  similar  comprehensive-type coverage shall
provide coverage for the screening, diagnosis and  treatment  of  autism
spectrum  disorder  in  accordance  with  this  paragraph  and shall not
exclude coverage for the screening, diagnosis or  treatment  of  medical
conditions  otherwise  covered  by  the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual  deductibles,  copayments  and  coinsurance  as  may  be   deemed
appropriate  by  the  superintendent  and shall be consistent with those
imposed on other benefits  under  the  group  or  blanket  policy.  This
paragraph  shall  not  be  construed  as  limiting the benefits that are
otherwise available to an individual under the group or blanket  policy,
provided  however  that such policy shall not contain any limitations on
visits that are solely applied  to  the  treatment  of  autism  spectrum
disorder.  No  insurer  shall  terminate  coverage or refuse to deliver,
execute, issue, amend, adjust, or renew coverage to an individual solely
because the individual is diagnosed with autism spectrum disorder or has
received treatment for  autism  spectrum  disorder.  Coverage  shall  be
subject  to  utilization  review  and  external  appeals  of health care
services pursuant to article forty-nine of this chapter as well as  case
management and other managed care provisions.
(C) For purposes of this paragraph:
(i)  "autism  spectrum  disorder"  means  any  pervasive developmental
disorder as defined in the most recent edition  of  the  diagnostic  and
statistical manual of mental disorders.
(ii) "applied behavior analysis" means the design, implementation, and
evaluation  of environmental modifications, using behavioral stimuli and
consequences, to  produce  socially  significant  improvement  in  human
behavior,  including  the  use  of  direct observation, measurement, and
functional   analysis   of  the  relationship  between  environment  and
behavior.
(iii) "behavioral health treatment"  means  counseling  and  treatment
programs,  when  provided  by  a licensed provider, and applied behavior
analysis, when provided by a person  licensed,  certified  or  otherwise
authorized  to  provide applied behavior analysis, that are necessary to
develop, maintain, or restore, to the maximum  extent  practicable,  the
functioning of an individual.
(iv)  "diagnosis  of  autism  spectrum  disorder"  means  assessments,
evaluations, or tests to  diagnose  whether  an  individual  has  autism
spectrum disorder.
(v)  "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight  of  the
education law.
(vi) "psychiatric care" means direct or consultative services provided
by  a  psychiatrist  licensed  in  the  state  in which the psychiatrist
practices.
(vii) "psychological  care"  means  direct  or  consultative  services
provided   by  a  psychologist  licensed  in  the  state  in  which  the
psychologist practices.
(viii) "therapeutic care"  means  services  provided  by  licensed  or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(ix)  "treatment  of  autism  spectrum  disorder"  shall  include  the
following care and assistive communication devices prescribed or ordered
for an individual diagnosed with autism spectrum disorder by a  licensed
physician or a licensed psychologist:
(1) behavioral health treatment;
(2) psychiatric care;
(3) psychological care;
(4) medical care provided by a licensed health care provider;
(5)  therapeutic  care,  including  therapeutic  care  which is deemed
habilitative or nonrestorative, in the event that  the  policy  provides
coverage for therapeutic care; and
(6)  pharmacy  care in the event that the policy provides coverage for
prescription drugs.
(D) Coverage may be denied on the basis that such treatment  is  being
provided  to  the covered person pursuant to an individualized education
plan under article eighty-nine of the education law.  The  provision  of
services pursuant to an individualized family service plan under section
twenty-five   hundred   forty-five   of   the   public  health  law,  an
individualized education plan under article eighty-nine of the education
law, or an individualized service plan pursuant to  regulations  of  the
office  for  persons  with  developmental  disabilities shall not affect
coverage under the policy for services provided on a supplemental  basis
outside  of  an educational setting if such services are prescribed by a
licensed physician or licensed psychologist.
(E) Nothing in  this  paragraph  shall  be  construed  to  affect  any
obligation  to provide services to an individual under an individualized
family service plan under section twenty-five hundred forty-five of  the
public  health  law,  an  individualized  education  plan  under article
eighty-nine of the education law,  or  an  individualized  service  plan
pursuant  to  regulations  of  the office for persons with developmental
disabilities.
(G) Nothing in this paragraph shall be construed to prevent a group or
blanket  policy  from  providing   services   through   a   network   of
participating   providers   who  shall  meet  certain  requirements  for
participation, including provider credentialing.
(H)   Coverage   under   this  paragraph  shall  not  apply  financial
requirements  or  treatment  limitations  to  autism  spectrum  disorder
benefits  that  are  more  restrictive  than  the  predominant financial
requirements and treatment  limitations  applied  to  substantially  all
medical and surgical benefits covered by the policy.
(I) The criteria for medical necessity determinations under the policy
with  respect  to  autism  spectrum  disorder  benefits  shall  be  made
available by  the  insurer  to  any  insured,  prospective  insured,  or
in-network provider upon request.
(J) For purposes of this paragraph:
(i)  "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(ii) "predominant" means that a  financial  requirement  or  treatment
limitation  is  the  most  common  or  frequent of such type of limit or
requirement; and
(iii)  "treatment  limitation"  means  limits  on  the  frequency   of
treatment,  number  of visits, days of coverage, or other similar limits
on the scope or  duration  of  treatment  and  includes  nonquantitative
treatment  limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on  whether  the
treatment  is  experimental  or  investigational;  formulary  design for
prescription  drugs;  network  tier  design;  standards   for   provider
admission  to  participate  in a network, including reimbursement rates;
methods  for  determining  usual,  customary,  and  reasonable  charges;
fail-first  or  step  therapy  protocols; exclusions based on failure to
complete a course of treatment; and  restrictions  based  on  geographic
location,  facility  type,  provider  specialty, and other criteria that
limit the scope or duration of benefits for services provided under  the
policy.
(K)  An  insurer  shall  provide  coverage  under this paragraph, at a
minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
1185a).
(18) (A) Definitions. For the purpose of this paragraph:
(i) "Same reimbursement amount" shall mean that any coverage described
under  subparagraph  (B)  of  this  paragraph  shall  provide  the  same
benchmark  index,  including  the  same average wholesale price, maximum
allowable cost and national prescription drug  codes  to  reimburse  all
pharmacies  participating in the insurance network regardless of whether
a pharmacy is a mail order pharmacy or a non-mail order pharmacy.
(ii) "Mail order pharmacy" means a pharmacy whose primary business  is
to   receive  prescriptions  by  mail,  telefax  or  through  electronic
submissions and to dispense medication to patients through  the  use  of
the  United States mail or other common or contract carrier services and
provides any  consultation  with  patients  electronically  rather  than
face-to-face.
(B)  Any  insurer  delivering  a  group or blanket policy or issuing a
group or blanket  policy  for  delivery  in  this  state  that  provides
coverage  for  prescription  drugs shall permit each insured to fill any
covered prescription that may be obtained  at  a  network  participating
mail  order  or other non-retail pharmacy, at the insured's option, at a
network participating non-mail order retail pharmacy provided  that  the
network  participating non-mail order retail pharmacy agrees to the same
reimbursement amount that the insurer has established  for  the  network

participating  mail  order or other non-retail pharmacy. In such a case,
the policy shall not impose a co-payment fee or other condition  on  any
insured  who  elects  to  purchase  drugs  from  a network participating
non-mail  order  retail  pharmacy  which is not also imposed on insureds
electing to purchase drugs from a network participating  mail  order  or
other  non-retail  pharmacy;  provided,  however, that the provisions of
this section shall not supersede the terms of  a  collective  bargaining
agreement  or  apply  to  a  policy  that  is the result of a collective
bargaining agreement between an employer and a recognized  or  certified
employee organization.
(19)  Whenever  in  this  section  an  insurer  is required to provide
benefits with no coinsurance or deductible, the requirement only applies
with respect to participating providers in  the  insurer's  network,  or
with  respect  to  non-participating  providers, if the insurer does not
have a participating provider in the in-network benefits portion of  its
network  with  the  appropriate  training  and  experience  to  meet the
particular health care needs of the insured pursuant to  subsection  (d)
of section three thousand two hundred seventeen-d of this article.
* (20) Health care forensic examinations performed pursuant to section
twenty-eight  hundred  five-i of the public health law covered under the
policy shall not be subject to annual deductibles or coinsurance.
* NB There are 2 par (20)'s
* (20) Every insurer delivering a group or blanket policy or issuing a
group or blanket  policy  for  delivery  in  this  state  that  provides
coverage  for  hospital,  surgical  or  medical  care  shall provide the
following coverage for pasteurized donor human milk  (PDHM),  which  may
include  fortifiers as medically indicated, for inpatient use, for which
a licensed medical practitioner has issued an order for an infant who is
medically or physically  unable  to  receive  maternal  breast  milk  or
participate in breast feeding or whose mother is medically or physically
unable  to  produce  maternal  breast  milk  at  all  or  in  sufficient
quantities or participate in breast feeding  despite  optimal  lactation
support.  Such  infant shall: (i) have a documented birth weight of less
than one thousand five hundred grams;  or  (ii)  have  a  congenital  or
acquired condition that places the infant at a high risk for development
of necrotizing enterocolitis.
* NB There are 2 par (20)'s
* (21) Every large group policy 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  policy,  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 par (21)'s
* (21) Every group or blanket policy delivered or issued for  delivery
in this state 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
paragraph only applies to a prescription  drug  that  is  either  (A)  a
brand-name drug without an AB rated generic equivalent, as determined by
the United States Food and Drug Administration; or (B) a brand-name drug
with  an AB rated generic equivalent, as determined by the United States
Food and  Drug  Administration,  and  the  insured  has  access  to  the
brand-name  drug  through  prior authorization by the insurer or through
the insurer's appeal process, including any step-therapy process; or (C)
a  generic  drug  the  insurer  will  cover,  with  or   without   prior
authorization or an appeal process.
* NB There are 2 par (21)'s
(m)  A  group  policy  providing hospital, surgical or medical expense
insurance for other than accident only shall provide that if all or  any
portion  of  the  insurance  on  an employee or member insured under the
policy ceases because of termination of employment or membership in  the
class  or  classes eligible for coverage under the policy, such employee
or member shall  be  entitled  without  evidence  of  insurability  upon
application  to  continue  his  hospital,  surgical  or  medical expense
insurance for himself or herself and his  or  her  eligible  dependents,
subject  to all of the group policy's terms and conditions applicable to
those forms of benefits and to the following conditions:
(1) Continuation shall cease on the date which the employee, member or
dependant first becomes, after the date of  election:  (A)  entitled  to
coverage  under  title  XVIII  of  the United States Social Security Act
(Medicare) as amended or superseded; or  (B)  covered  as  an  employee,
member  or dependent by any other insured or uninsured arrangement which
provides hospital, surgical or medical coverage  for  individuals  in  a
group which does not contain any exclusion or limitation with respect to
any pre-existing condition of such employee, member or dependent, except
the  group  insurance policy conversion option of this section shall not
be considered as such an arrangement under which an employee, member  or
dependent could become covered.
(2) (A) An employee or member who wishes continuation of coverage must
request  such  continuation  in  writing  within  the  sixty  day period
following the later of: (i) the date of such termination;  or  (ii)  the
date  the  employee  is  sent notice by first class mail of the right of
continuation by the group policyholder.
(B) An employee or member who wishes continuation  of  coverage  under
subparagraph  (D)  of paragraph four of this subsection must give notice
to  the  employer  or  group  policyholder  within  sixty  days  of  the
determination  under  title  II or title XVI of the United States Social
Security Act that such employee or member was disabled at  the  time  of
termination  of employment or membership or at any time during the first
sixty days of continuation of coverage.
(3) An employee or member electing continuation must pay to the  group
policyholder  or his employer, but not more frequently than on a monthly
basis in advance, the amount of the required premium  payment,  but  not
more  than  one  hundred  two percent of the group rate for the benefits
being continued under the group policy on the due date of each  payment.
The  employee's  or  member's written election of continuation, together
with the first premium payment required to establish premium payment  on
a  monthly  basis  in  advance,  must  be  given  to the policyholder or

employer within sixty days  of  the  date  the  employee's  or  member's
benefits would otherwise terminate.
(4)  Subject  to  paragraph  one  of  this subsection, continuation of
benefits under the group policy for any person shall  terminate  at  the
first to occur of the following:
(A)  The  date  thirty-six  months  after  the  date the employee's or
member's benefits under  the  policy  would  otherwise  have  terminated
because of termination of employment or membership; or
(B) The end of the period for which premium payments were made, if the
employee  or  member  fails to make timely payment of a required premium
payment; or
(C) In the case of an eligible dependent of an employee or member, the
date thirty-six months after the date such person's benefits  under  the
policy would otherwise have terminated by reason of:
(i) the death of the employee or member;
(ii)  the  divorce  or legal separation of the employee or member from
his or her spouse;
(iii) the employee or member becoming entitled to benefits under title
XVIII of the United States Social Security Act (Medicare); or
(iv) a dependent child ceasing to  be  a  dependent  child  under  the
generally applicable requirements of the policy; or
(D)  The  date on which the group policy is terminated or, in the case
of an employee, the date his employer terminates participation under the
group policy. However, if this clause applies and the  coverage  ceasing
by  reason  of  such  termination  is replaced by similar coverage under
another group policy, the following shall apply:
(i) The employee or member shall have  the  right  to  become  covered
under  that  other  group  policy, for the balance of the period that he
would have remained covered under the prior group policy  in  accordance
with  this subparagraph had a termination described in this subparagraph
not occurred, and
(ii) The minimum level of benefits to be provided by the  other  group
policy  shall  be  the  applicable  level of benefits of the prior group
policy reduced by any benefits payable under that  prior  group  policy,
and
(iii) The prior group policy shall continue to provide benefits to the
extent  of  its  accrued liabilities and extension of benefits as if the
replacement had not occurred.
(5) A notification of the continuation privilege and the  time  period
in  which  to request continuation shall be included in each certificate
of coverage.
(6) This subsection shall  not  be  applicable  where  a  continuation
benefit is available to the employee or member pursuant to Chapter 18 of
the  Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or
Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb -  1  et
seq.  However,  a  group policy shall offer an insured who has exhausted
continuation coverage pursuant to Chapter 18 of the Employee  Retirement
Income  Security  Act,  29  U.S.C.  §  1161 et seq. or Chapter 6A of the
Public Health Service  Act,  42  U.S.C.  §  300  bb  -  1  et  seq.  the
opportunity  to  continue  coverage for up to thirty-six months from the
date the employee's or member's  continuation  coverage  began,  if  the
employee  or  member  is  entitled  to  less  than  thirty-six months of
continuation benefits under federal law.
(7)(A) Special enrollment period. An individual who does not  have  an
election  of  continuation  coverage  as described in this subsection in
effect on the effective date of the American Recovery  and  Reinvestment
act  of  2009,  but who would be an assistance eligible individual under
Title III of such act  if  such  election  were  in  effect,  may  elect

continuation  coverage  pursuant to this subsection. Such election shall
be made no later than sixty days after the date the administrator of the
group health  plan  (or  other  entity  involved)  provides  the  notice
required by section 3001(a)(7) of the American Recovery and Reinvestment
act of 2009. The administrator of the group health plan (or other entity
involved)  shall  provide such individuals with additional notice of the
right to elect coverage pursuant to this paragraph within sixty days  of
the  date  of enactment of the American Recovery and Reinvestment act of
2009.
(B) Continuation coverage elected pursuant to subparagraph (A) of this
paragraph shall commence with the first period of coverage beginning  on
or  after  the  date  of  the  enactment  of  the  American Recovery and
Reinvestment act of 2009 and shall  not  extend  beyond  the  period  of
continuation  coverage that would have been required if the coverage had
instead been elected pursuant to paragraph two of this subsection.
(C) With respect to an individual  who  elects  continuation  coverage
pursuant  to subparagraph (A) of this paragraph, the period beginning on
the date of the qualifying event and ending on the  date  of  the  first
period  of  coverage  on or after the enactment of the American Recovery
and Reinvestment act of  2009  shall  be  disregarded  for  purposes  of
determining  the  sixty-three  day  period  referred to in section three
thousand two hundred thirty-two of this article.
(8) For purposes  of  this  subsection,  the  term  "dependent"  shall
include  a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.
(n) In addition to all  the  rights  of  conversion  and  continuation
otherwise  provided  for  herein, employees or members insured under the
policy who are also members of a reserve component of the  armed  forces
of the United States, including the National Guard, shall be entitled to
have   supplementary  conversion  and  continuation  rights  in  certain
circumstances as follows:
(1) If the employee or member  insured  enters  upon  active  duty  as
defined  in  subsection  (o)  of this section, and the employer or group
policyholder does not voluntarily maintain coverage for such employee or
member insured, the employee or member insured shall be entitled to have
his or her coverage continued under the group policy in accordance  with
the  conditions  and  limitations  contained  in paragraph seven of this
subsection and have issued at the end of the period of  continuation  an
individual  conversion  policy  subject to the terms of this subsection.
The effective date for the conversion policy shall be the day  following
the  termination  of  insurance under the group policy, or if there is a
continuation of coverage on the day following the end of the  period  of
continuation.
(2)  If  the  employer  or  group  policyholder  does  not voluntarily
maintain coverage for the employee or member insured during  the  period
of  active  duty, and such employee or member insured does not elect the
supplementary conversion and continuation rights  provided  for  herein,
coverage  for  such employee or member insured shall be suspended during
the period of active duty.
(3) If  the  employee  or  member  insured  elects  the  supplementary
continuation  right provided for herein or coverage under the group plan
is suspended, and such employee or member insured dies during the period
of active duty, the conversion right provided by this section  shall  be
available  to  the surviving spouse and children, and shall be available
to a child solely with respect to himself or herself  upon  his  or  her
attaining  the  limiting  age  of  coverage under the group policy while
covered as a dependent thereunder. It shall also be available  upon  the
divorce  or annulment of the marriage of the employee or member insured,

to the former spouse of such employee or member insured, if such divorce
or annulment occurs during the period of active duty.
(4)  If  the  employee  or  member  insured  elects  the supplementary
conversion and continuation right provided for herein or coverage  under
the  group  plan  is  suspended,  and such employee or member insured is
either reemployed or restored to participation in the group upon  return
to  civilian status, he or she shall be entitled to resume participation
in insurance offered by the group pursuant  to  this  section,  with  no
limitations  or  conditions imposed as a result of such period of active
duty except as set forth in subparagraphs (A) and (B) herein. The  right
of  resumption  provided  for  herein  shall  extend to coverage for the
spouse and dependents of the employee or member insured and shall be  in
addition  to other existing rights granted pursuant to state and federal
laws and regulations and shall not be deemed to qualify  or  limit  such
rights  in  any  way.  No  exclusion or waiting period may be imposed in
connection with coverage of a health or physical condition of  a  person
entitled  to such right of resumption, or a health or physical condition
of any other person who is covered by the policy unless:
(A) the condition arose during the  period  of  active  duty  and  the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(B)  a  waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall  the  sum  of  the
waiting  periods  imposed  prior  to  and  subsequent  to  the period of
suspension exceed the length of the waiting period originally imposed.
(5) If  the  employee  or  member  insured  elects  the  supplementary
conversion and continuation coverage provided for herein:
(A)  when  such  employee  or  member  insured is either reemployed or
restored to participation in the group, coverage under the supplementary
rights provided for herein shall terminate on the date that coverage  is
effective due to resumption of participation in the group.
(B) when such employee or member insured is not reemployed or restored
to  participation in the group upon return to civilian status, he or she
shall be entitled to the conversion and continuation rights provided  by
subsections (e) and (m) of this section.
(i)  To  elect  an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must  apply  to  the
insurer  within  thirty-one  days  of  the termination of active duty or
discharge from hospitalization  incident  to  such  active  duty,  which
hospitalization  continues  for a period of not more than one year. Upon
commencement of coverage under the conversion right provided pursuant to
subsection  (e)  of  this  section,  coverage  under  the  supplementary
continuation right provided for herein shall terminate.
(ii) To elect continuation of coverage pursuant to subsections (e) and
(m)  of  this  section, the employee or member insured must request such
continuation of the employer within thirty-one days of  the  termination
of active duty or discharge from hospitalization incident to such active
duty,  which hospitalization continues for a period of not more than one
year.  Upon  commencement  of  coverage  under  the  continuation  right
provided  pursuant to subsection (e) of this section, coverage under the
supplementary continuation right provided for  herein  shall  terminate.
The  employee  or member insured shall be entitled to have issued at the
end of the period of continuation an individual conversion policy.
(6) If coverage under the group plan is suspended during the period of
active duty:
(A) when the employee or member insured returns  to  participation  in
the  group  plan,  coverage under the group plan shall be retroactive to
the date of termination of the period of active duty.
(B) when such employee or member insured is not reemployed or restored
to participation in the group upon return to civilian status, he or  she
shall  be entitled to the conversion and continuation rights provided by
subsections (e) and (m) of this section.
(i)  To  elect  an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must  apply  to  the
insurer  within  thirty-one  days  of  the termination of active duty or
discharge from hospitalization  incident  to  such  active  duty,  which
hospitalization continues for a period of not more than one year.
(ii) To elect continuation of coverage pursuant to subsections (e) and
(m)  of  this  section, the employee or member insured must request such
continuation of the employer within thirty-one days of  the  termination
of active duty or discharge from hospitalization incident to such active
duty,  which hospitalization continues for a period of not more than one
year. The employee or member insured shall be entitled to have issued at
the end of the period of continuation an individual conversion policy.
(7) A group policy providing hospital,  surgical  or  medical  expense
insurance  for other than accident only shall provide that if all or any
portion of the insurance on an employee  or  member  insured  under  the
policy  ceases  because  the  employee  or  member insured is ordered to
active duty as defined in subsection (o) of this section, such  employee
or  member  insured shall be entitled, without evidence of insurability,
upon application to continue his or her hospital,  surgical  or  medical
expense  insurance  for  himself  or  herself  and  his  or her eligible
dependents, under the supplementary conversion and  continuation  rights
provided  for  herein,  subject  to  all of the group policy's terms and
conditions applicable to those forms of benefits and  to  the  following
conditions:
(A)  continuation  shall  not  be available for: (i) any person who is
covered, becomes covered or could be  covered  by  title  XVIII  of  the
United States Social Security Act (Medicare) as amended or superseded or
(ii) an employee, member or dependent who is covered, becomes covered or
could  become  covered  as an employee, member or dependent by any other
insured or uninsured arrangement which provides  hospital,  surgical  or
medical  coverage  for  individuals in a group, except that the coverage
available to active duty members of the  uniformed  services  and  their
family  members  shall not be considered a group under the terms of this
subsection, and except that the group insurance policy conversion option
of this section shall not be considered as  such  an  arrangement  under
which an employee, member or dependent could become covered.
(B)  an employee or member insured who wishes continuation of coverage
pursuant to this subsection must request such  continuation  in  writing
within sixty days of being ordered to active duty.
(C)  an  employee  or member insured electing continuation pursuant to
this subsection must pay  to  the  group  policyholder  or  his  or  her
employer,  but  not  more frequently than on a monthly basis in advance,
the amount of the required premium payment, but not more than the  group
rate  for the benefits being continued under the group policy on the due
date of each payment.
(8) The supplementary conversion and continuation rights provided  for
herein shall apply to:
(A)  policies  not  covered  by  Chapter 18 of the Employee Retirement
Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of  the
Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;
(B)  policies  covered by Chapter 18 of the Employee Retirement Income
Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the  Public
Health  Service  Act, 42 U.S.C. section 300bb-1 et seq, when active duty
for reservists and the refusal of an employer  to  voluntarily  maintain

coverage  for  such period of active duty is not considered a qualifying
event.
(o)  To  be  entitled  to  the right defined in subsection (n) of this
section a person must be a member of a reserve component  of  the  armed
forces of the United States, including the National Guard, who either:
(A)  voluntarily  or involuntarily enters upon active duty (other than
for the purpose of determining his or her  physical  fitness  and  other
than for training), or
(B)  has  his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units  of  the
ready reserve or members of a reserve component to active duty, provided
that  such  additional  active  duty  is  at  the  request  and  for the
convenience of the federal government, and
(C) serves no more than four years of active duty.
(p)(1) Except as provided in this section, if an insurer  delivers  or
issues  for  delivery  in  this  state  a  group or blanket policy which
provides hospital, surgical or medical expense coverage for  other  than
accident only, the insurer must renew or continue in force such coverage
at the option of the policyholder.
(2) An insurer may nonrenew or discontinue coverage under such a group
or blanket policy based only on one or more of the following:
(A)  The  policyholder  or  a  participating  entity has failed to pay
premiums or contributions in accordance with the terms of the policy  or
the insurer has not received timely premium payments.
(B) The policyholder or a participating entity has performed an act or
practice that constitutes fraud or made an intentional misrepresentation
of material fact under the terms of the coverage.
(C)  The  policyholder  has  failed  to  comply  with  a material plan
provision relating  to  employer  contribution  or  group  participation
rules,  as permitted under section four thousand two hundred thirty-five
of this chapter.
(D) The insurer is ceasing to offer group or  blanket  policies  in  a
market in accordance with paragraph three or seven of this subsection.
(E) The policyholder ceases to meet the requirements for a group under
section  four  thousand  two  hundred  thirty-five  of this chapter or a
participating employer, labor union, association or other entity  ceases
membership  or participation in the group to which the policy is issued.
Coverage terminated pursuant to this paragraph shall be  done  uniformly
without  regard  to  any  health  status-related  factor relating to any
covered individual.
(F) In the case of an insurer that offers a group or blanket policy in
a market through a network plan, there is  no  longer  any  enrollee  in
connection  with  such  plan who lives, resides, or works in the service
area of the insurer (or in the area for which the insurer is  authorized
to do business).
(G)  Such  other  reasons  as are acceptable to the superintendent and
authorized by the Health Insurance Portability and Accountability Act of
1996,  Public  Law  104-191,  and  any  later  amendments  or  successor
provisions,  or  by  any federal regulations or rules that implement the
provisions of the Act.
(3)(A) In any case in which an insurer decides to discontinue offering
a particular class of group or blanket policy of hospital,  surgical  or
medical  expense  insurance  offered in the small or large group market,
the policy  of  such  class  may  be  discontinued  by  the  insurer  in
accordance with this chapter in such market only if:
(i)  the insurer provides written notice to each policyholder provided
coverage of this class in such market (and to all employees  and  member
insureds  covered  under  such coverage) of such discontinuance at least

ninety days prior to the date of discontinuance  of  such  coverage.  In
addition   to   any   other  information  required  of  notices  by  the
superintendent, this  written  notice  shall  conspicuously  include  an
explanation,  in  plain  language,  of  the  policyholder's  and covered
employee's or member insured's rights under this subparagraph and (B) of
this paragraph, including:
(I) a statement that if the superintendent determines that the covered
employee,  member  insured,  or  a  dependent  has  a  serious   medical
condition,  and the covered employee, member insured or dependent within
the previous twelve months utilized a benefit under the  policy  related
to  the serious medical condition that is not covered by the replacement
coverage offered to the policyholder as a result of the  discontinuance,
then   the  superintendent  shall  require  the  insurer  to  offer  the
policyholder replacement coverage that includes a benefit  that  is  the
same  as or substantially similar to the benefit set forth in the policy
that the insurer discontinued; and
(II) an explanation as to how to contact the superintendent,  and  the
date   by   which   the   superintendent  shall  be  contacted,  if  the
policyholder, covered employee  or  member  insured  believes  that  the
covered  employee,  member  insured or a dependent has a serious medical
condition, and the covered employee, member insured or dependent  within
the  previous  twelve  months  utilized a benefit related to the serious
medical condition that may not be covered by  the  replacement  coverage
offered to the policyholder as a result of the discontinuance;
(ii) the insurer offers to each policyholder provided coverage of this
class in such market, the option to purchase all (or, in the case of the
large  group  market,  any) other hospital, surgical and medical expense
coverage currently being offered by the  insurer  to  a  group  in  such
market;
(iii)  in  exercising the option to discontinue coverage of this class
and in  offering  the  option  of  coverage  under  item  (ii)  of  this
subparagraph,  the  insurer  acts uniformly without regard to the claims
experience of those policyholders or any  health  status-related  factor
relating to any particular covered employee, member insured or dependent
or  particular  new employee, member insured or dependent who may become
eligible for such coverage, and the insurer  is  not  discontinuing  the
coverage  of this class with the intent or as a pretext to discontinuing
the coverage of any such employee, member insured or dependent; and
(iv) at least ninety days prior to the date of discontinuance of  such
coverage,  the  insurer provides written notice to the superintendent of
such discontinuance, including the reason for the discontinuance, and an
officer or director of the insurer certifies to the superintendent  that
the  insurer  has  complied  with  items  (i),  (ii)  and  (iii) of this
paragraph. If such notice does not include the date or  dates  that  the
insurer  mailed  or  delivered  the notice to all policyholders, covered
employers  and  member  insureds,   the   insurer   shall   notify   the
superintendent  of  such date within seven days of the completion of the
mailing or delivery.
(B) If the superintendent determines that the insurer has not complied
with item  (iii)  of  subparagraph  (A)  of  this  paragraph,  then  the
superintendent  may prohibit the insurer from discontinuing the class of
policies and require the insurer to promptly notify every  policyholder,
covered   employee   and   member   insured  that  the  insurer  is  not
discontinuing the policies. If the superintendent  determines  that  the
insurer  wrongfully  discontinued the class of policies pursuant to item
(iii) of subparagraph (A), then the superintendent  shall  require  that
the   insurer   take   remedial  action,  including  offering  to  group
policyholders the option of reinstating the discontinued  policy  forms.

If the superintendent determines that the insurer discontinued the class
of  policies  without  compliance  with  items  (i),  (ii),  or  (iv) of
subparagraph (A), and an employee, member insured or  dependent  covered
under  the  discontinued policy would have been entitled to relief under
this paragraph, then the superintendent may  require  that  the  insurer
offer  replacement  coverage to an affected policyholder consistent with
item (ii) of subparagraph (C) of this paragraph.
(C) (i) If, within forty-five days after the insurer mails or delivers
the  written  notice  of  discontinuance  required  by   item   (i)   of
subparagraph  (A) of this paragraph, the superintendent is notified by a
policyholder or covered  employee  or  member  insured  that  a  covered
employee,  member  insured  or dependent has a serious medical condition
and that a benefit utilized by the covered employee, member  insured  or
dependent  within  the  previous  twelve  months  related to the serious
medical condition may not be covered by the replacement coverage offered
to the  policyholder  as  a  result  of  the  discontinuance,  then  the
superintendent  shall,  within  twenty days of the notification, ask the
insurer  to  confirm  that  the  covered  employee,  member  insured  or
dependent  utilize  a benefit within the previous twelve months to treat
the medical condition that  the  covered  employee,  member  insured  or
dependent  asserts  is a serious medical condition, and that the benefit
is not covered by  the  replacement  coverage.  The  superintendent  may
request  such  additional information as the superintendent may require.
The  insurer  shall   provide   all   requested   information   to   the
superintendent within five days of receipt of the request.
(ii)  If,  within  twenty  days of the superintendent's receipt of all
additional information requested from the  insurer,  the  superintendent
determines  that  (I)  the covered employee, member insured or dependent
has a serious medical condition; and (II) the benefit  utilized  by  the
covered employee, member insured or dependent within the previous twelve
months  related  to  the serious medical condition is not covered by the
replacement coverage offered to the policyholder  as  a  result  of  the
discontinuance,  then  the  superintendent  shall require the insurer to
offer to the policyholder replacement coverage that includes  a  benefit
that is the same as or substantially similar to the benefit set forth in
the policy that the insurer discontinued. If the replacement coverage is
not   available,  at  the  time  that  the  policy  would  otherwise  be
discontinued, then the insurer shall keep the existing policy  in  force
for  the  affected  policyholder until the replacement coverage with the
substantially similar benefit is available.
(D) The remedies as provided in this paragraph shall be in addition to
and not in lieu of any other authority or power of the superintendent to
impose monetary or other penalties for violations of this paragraph.
(E) In any case in which an insurer elects to discontinue offering all
hospital, surgical and medical  expense  coverage  in  the  small  group
market or the large group market, or both markets, in this state, health
insurance coverage may be discontinued by the insurer only if:
(i)  the  insurer provides written notice to the superintendent and to
each policyholder (and all employees and member insureds  covered  under
such  coverage)  of such discontinuance at least one hundred eighty days
prior to the date of the discontinuance of such coverage;
(ii) all hospital, surgical and medical  expense  coverage  issued  or
delivered  for  issuance  in  this  state in such market (or markets) is
discontinued and  coverage  under  such  policies  in  such  market  (or
markets) is not renewed; and
(iii)  in  addition to the notice to the superintendent referred to in
item  (i)  of  this  subparagraph,  the  insurer   shall   provide   the

superintendent  with  a written plan to minimize potential disruption in
the marketplace occasioned by the insurer's withdrawal from the market.
(F)  In  the  case  of  a discontinuance under subparagraph (E of this
paragraph in a market, the insurer may not provide for the  issuance  of
any  group  or  blanket  policy of hospital, surgical or medical expense
insurance in that market in this  state  during  the  five  year  period
beginning on the date of the discontinuance of the last health insurance
policy not so renewed.
(4)  At the time of coverage renewal, an insurer may modify the health
insurance coverage for a group or blanket policy offered to a  large  or
small group policyholder so long as such modification is consistent with
this  chapter  and  effective  on  a uniform basis among all small group
policyholders with that policy form.
(5) For purposes of this subsection the term "network plan" shall mean
a health insurance policy under which  the  financing  and  delivery  of
health  care  (including  items  and services paid for as such care) are
provided, in whole or in part, through a defined set of providers  under
contract  either with the insurer or another entity which has contracted
with the insurer.
(6) For purposes  of  this  subsection,  the  term  "dependent"  shall
include  a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.
(7) Notwithstanding paragraph three of this subsection, an insurer may
discontinue offering a particular class of group or  blanket  policy  of
hospital,  surgical or medical expense insurance offered in the small or
large group market, and instead offer  a  group  or  blanket  policy  of
hospital,  surgical  or medical expense insurance that complies with the
requirements of section 2707 of the public  health  service  act,  §  42
U.S.C.  300gg-6  that  become  applicable  to  such policy as of January
first, two thousand fourteen, provided that the insurer:
(A) discontinues the existing class of policy in  such  market  as  of
either  December  thirty-first,  two  thousand  thirteen  or  the policy
renewal date occurring in two thousand fourteen in accordance with  this
chapter;
(B)  provides written notice to each policyholder provided coverage of
the class in the market  (and  to  all  employees  and  member  insureds
covered  under such coverage) of the discontinuance at least ninety days
prior to the date of discontinuance of such coverage. The written notice
shall be in a form satisfactory to the superintendent;
(C) offers to each policyholder provided coverage of the class in  the
market,  the  option to purchase all (or, in the case of the large group
market, any) other hospital, surgical and medical expense coverage  that
complies  with  the  requirements  of  section 2707 of the public health
service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage
as of January first, two thousand fourteen, currently being  offered  by
the insurer to a group in that market;
(D)  in exercising the option to discontinue coverage of the class and
in offering the option  of  coverage  under  subparagraph  (C)  of  this
paragraph,  acts  uniformly  without  regard to the claims experience of
those policyholders or any health status-related factor relating to  any
particular  covered employee, member insured or dependent, or particular
new employee, member insured, or dependent who may become  eligible  for
such  coverage,  and does not discontinue the coverage of the class with
the intent or as a pretext to discontinuing the  coverage  of  any  such
employee, member insured, or dependent; and
(E)  at  least  one  hundred  twenty  days  prior  to  the date of the
discontinuance  of  such  coverage,  provides  written  notice  to   the
superintendent  of  the  discontinuance,  including  certification by an

officer  or  director  of  the  insurer  that   the   reason   for   the
discontinuance  is  to  replace  the  coverage  with  new  coverage that
complies with the requirements of section  2707  of  the  public  health
service  act,  §  42 U.S.C. 300gg-6 that become effective January first,
two thousand fourteen. The written notice shall  be  in  such  form  and
contain such information the superintendent requires.
(q)(1)  No  insurer delivering or issuing for delivery in this state a
group or blanket policy which provides  hospital,  surgical  or  medical
expense  coverage  shall  establish  rules  for  eligibility  (including
continued eligibility) of any individual or dependent of the  individual
to  enroll  under  the  policy  based  on  any  of  the following health
status-related factors:
(A) Health status.
(B) Medical condition (including both physical and mental illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising out of acts
of domestic violence).
(H) Disability.
(2) For purposes of  paragraph  one  of  this  subsection,  rules  for
eligibility  include  rules  defining any applicable waiting periods for
such enrollment.
(3) No insurer may, on the basis of any health  status-related  factor
in  relation  to  the  insured  or dependent of the insured, require any
insured (as a condition of enrollment or continued enrollment under  the
policy)  to  pay  a  premium  or contribution which is greater than such
premium for a similarly situated insured enrolled in the plan.
(4) Nothing in this subsection shall require an  insurer  to  issue  a
group  or blanket policy to a group comprised of fifty-one or more lives
exclusive of spouses and dependents.
(5) Where an eligible insured  or  dependent  of  an  insured  rejects
initial  enrollment in a group or blanket policy that provides hospital,
surgical or medical  expense  insurance,  an  insurer  shall  permit  an
insured  or  dependent  of  an  insured to enroll for coverage under the
terms of the policy if each of the following conditions is met:
(A) The insured or dependent was covered under another plan or  policy
at the time coverage was initially offered.
(B)(i)  Coverage  under  the  other  plan  or  policy  was provided in
accordance with continuation required by federal or state  law  and  was
exhausted; or
(ii)  Coverage  under  the  other  plan  or  policy  was  subsequently
terminated as a result of loss of eligibility for one  or  more  of  the
following reasons:
(I) termination of employment;
(II) termination of the other plan or policy;
(III) death of the spouse;
(IV) legal separation, divorce, or annulment;
(V) reduction in the number of hours of employment; or
(iii) Policyholder contributions toward the payment of premium for the
other plan or contract were terminated.
(C) Coverage must be applied for within thirty days of termination for
one of the reasons set forth in subparagraph (B) of this paragraph.
(6)  With respect to group or blanket policies delivered or issued for
delivery in this state covering  between  two  and  fifty  employees  or
members,  the provisions of this subsection shall in no way diminish the

rights of such groups pursuant to section  three  thousand  two  hundred
thirty-one of this article.
(7)  For  purposes  of  this  subsection,  the  term "dependent" shall
include a child as described in subsection (f) of section four  thousand
two hundred thirty-five of this chapter.
(r)  (1)  As used in this subsection, "child" means an unmarried child
through age twenty-nine of an employee or member insured under  a  group
policy of hospital, medical or surgical expense insurance, regardless of
financial  dependence,  who  is  not insured by or eligible for coverage
under any employer health benefit plan as an employee or member, whether
insured or self-insured, and who lives, works or  resides  in  New  York
state  or  the  service area of the insurer and who is not covered under
title XVIII of the United States Social Security Act (Medicare).
(2) In addition to the conversion privilege afforded by subsection (e)
of this section and the continuation privilege  afforded  by  subsection
(m) of this section, every group policy delivered or issued for delivery
in  this  state  that  provides  hospital,  medical  or surgical expense
insurance coverage for other than specific diseases or  accidents  only,
and  which  provides  coverage of a child that terminates at a specified
age, shall, upon application of the employee, member or  child,  as  set
forth  in  subparagraph  (B)  of this paragraph, provide coverage to the
child after that specified  age  and  through  age  twenty-nine  without
evidence  of insurability, subject to all of the terms and conditions of
the group policy and the following:
(A) An employer shall not be required to pay all or part of  the  cost
of coverage for a child provided pursuant to this subsection;
(B)  An  employee, member or child who wishes to elect continuation of
coverage pursuant to this subsection shall request the  continuation  in
writing:
(i)  within  sixty  days  following  the date coverage would otherwise
terminate due to reaching the specified  age  set  forth  in  the  group
policy;
(ii) within sixty days after meeting the requirements for child status
set  forth  in  paragraph  one  of this subsection when coverage for the
child previously terminated; or
(iii) during an annual thirty-day open enrollment period, as described
in the policy;
(C) An employee, member or child electing continuation as described in
this subsection shall pay to the group policyholder or employer, but not
more frequently than on a monthly basis in advance, the  amount  of  the
required  premium  payment  on the due date of each payment. The written
election of  continuation,  together  with  the  first  premium  payment
required  to  establish  premium  payment on a monthly basis in advance,
shall be given to the group policyholder or  employer  within  the  time
periods  set  forth  in  subparagraph (B) of this paragraph. Any premium
received within the thirty-day  period  after  the  due  date  shall  be
considered timely;
(D)  For any child electing coverage within sixty days of the date the
child would otherwise lose coverage due to reaching a specified age, the
effective date of the continuation coverage shall be the  date  coverage
would  have  otherwise  terminated.  For  any  child  electing to resume
coverage during an annual open enrollment period, the effective date  of
the continuation coverage shall be prospective no later than thirty days
after the election and payment of first premium;
(E)  Coverage for a child pursuant to this subsection shall consist of
coverage that is identical to the coverage provided to the  employee  or
member parent. If coverage is modified under the policy for any group of

similarly situated employees or members, then the coverage shall also be
modified in the same manner for any child;
(F) Coverage shall terminate on the first to occur of the following:
(i)  the  date the child no longer meets the requirements of paragraph
one of this subsection;
(ii) the end of the period for which premium payments  were  made,  if
there  is a failure to make payment of a required premium payment within
the period of grace described in subparagraph (C) of this paragraph; or
(iii) the date on  which  the  group  policy  is  terminated  and  not
replaced by coverage under another group policy; and
(G) The insurer shall provide written notification of the continuation
privilege  described  in this subsection and the time period in which to
request continuation to the employee or member:
(i) in each certificate of coverage; and
(ii) at least sixty days prior to termination at the specified age  as
provided in the policy.
(3)(A)  Insurers  shall submit such reports as may be requested by the
superintendent to evaluate the effectiveness  of  coverage  pursuant  to
this  subsection  including,  but  not  limited to, quarterly enrollment
reports.
(B) The  superintendent  may  promulgate  regulations  to  ensure  the
orderly  implementation  and  operation  of  the  continuation  coverage
provided  pursuant  to   this   subsection,   including   premium   rate
adjustments.
(s)  An  insurer  subject  to  the  provisions  of  this article or an
insurance producer subject to this chapter shall not permit the  renewal
of  a  small  group  policy  that provides hospital, surgical or medical
expense coverage that renews on or after  January  first,  two  thousand
fourteen,  but  before July first, two thousand fourteen, so as to renew
the same policy prior to the policy's annual renewal date for  the  sole
purpose  of  evading  the  requirements  of  the affordable care act and
regulations promulgated thereunder  with  respect  to  such  policy.  An
isolated,  inadvertent  renewal  date  change which was not made for the
sole purpose of evading the requirements  of  the  affordable  care  act
shall not be deemed a violation of this subsection.
(t) (1) Any insurer that delivers or issues for delivery in this state
hospital,  surgical or medical expense group policies in the small group
or large group market shall offer to any employer in this state all such
policies in the  applicable  market,  and  shall  accept  at  all  times
throughout the year any employer that applies for any of those policies.
(2)  The  requirements of paragraph one of this subsection shall apply
with respect to an employer that applies for  coverage  either  directly
from the insurer or through an association or trust to which the insurer
has issued coverage and in which the employer participates.