N.Y. Ins. Law § 4303

§ 4303. Benefits. (a) Every contract issued by a hospital service\ncorporation or health service corporation which provides coverage for\nin-patient hospital care shall also provide coverage:\n (1) For preadmission testing performed in hospital facilities prior to\nscheduled surgery. A patient who uses the out-patient facilities of a\nhospital shall be entitled to benefits for tests ordered by a physician\nwhich are performed as a planned preliminary to admission of the patient\nas an in-patient for surgery in the same hospital, provided that:\n (A) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed,\n (B) reservations for a hospital bed and for an operating room shall\nhave been made prior to the performance of the tests,\n (C) surgery actually takes place within seven days of such presurgical\ntests, and\n (D) the patient is physically present at the hospital for the tests.\n (2) (A) For services to treat an emergency condition in hospital\nfacilities:\n (i) without the need for any prior authorization determination;\n (ii) regardless of whether the health care provider furnishing such\nservices is a participating provider with respect to such services;\n (iii) if the emergency services are provided by a non-participating\nprovider, without imposing any administrative requirement or limitation\non coverage that is more restrictive than the requirements or\nlimitations that apply to emergency services received from participating\nproviders; and\n (iv) if the emergency services are provided by a non-participating\nprovider, the cost-sharing requirement (expressed as a copayment or\ncoinsurance) shall be the same requirement that would apply if such\nservices were provided by a participating provider.\n (B) Any requirements of section 2719A(b) of the Public Health Service\nAct, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the\nrequirements of this paragraph with respect to coverage of emergency\nservices shall be applicable to every contract subject to this\nparagraph.\n (C) For the purpose of this provision, "emergency condition" means a\nmedical or behavioral condition that manifests itself by acute symptoms\nof sufficient severity, including severe pain, such that a prudent\nlayperson, possessing an average knowledge of medicine and health, could\nreasonably expect the absence of immediate medical attention to result\nin (i) placing the health of the person afflicted with such condition in\nserious jeopardy, or in the case of a behavioral condition placing the\nhealth of such person or others in serious jeopardy; (ii) serious\nimpairment to such person's bodily functions; (iii) serious dysfunction\nof any bodily organ or part of such person; (iv) serious disfigurement\nof such person; or (v) a condition described in clause (i), (ii) or\n(iii) of section 1867(e)(1)(A) of the Social Security Act.\n (D) For the purpose of this provision, "emergency services" means,\nwith respect to an emergency condition: (i) a medical screening\nexamination as required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, which is within the capability of the emergency\ndepartment of a hospital, including ancillary services routinely\navailable to the emergency department to evaluate such emergency medical\ncondition; and (ii) within the capabilities of the staff and facilities\navailable at the hospital, such further medical examination and\ntreatment as are required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, to stabilize the patient.\n (E) For the purpose of this provision, "to stabilize" means, with\nrespect to an emergency condition, to provide such medical treatment of\nthe condition as may be necessary to assure, within reasonable medical\nprobability, that no material deterioration of the condition is likely\nto result from or occur during the transfer of the subscriber from a\nfacility or to deliver a newborn child (including the placenta).\n (3) For home care to residents in this state. Such home care coverage\nshall be included at the inception of all new contracts and, with\nrespect to all other contracts, added at any anniversary date of the\ncontract subject to evidence of insurability. Such coverage may be\nsubject to an annual deductible of not more than fifty dollars for each\ncovered person and may be subject to a coinsurance provision which\nprovides for coverage of not less than seventy-five percent of the\nreasonable cost of services for which payment may be made. No such\ncorporation need provide such coverage to persons eligible for medicare.\n (A) Home care shall mean the care and treatment of a covered person\nwho is under the care of a physician but only if:\n (i) hospitalization or confinement in a nursing facility as defined in\nsubchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq,\nwould otherwise have been required if home care was not provided, and\n (ii) the plan covering the home health service is established and\napproved in writing by such physician.\n (B) Home care shall be provided by an agency possessing a valid\ncertificate of approval or license issued pursuant to article thirty-six\nof the public health law.\n (C) Home care shall consist of one or more of the following:\n (i) part-time or intermittent home nursing care by or under the\nsupervision of a registered professional nurse (R.N.),\n (ii) part-time or intermittent home health aide services which consist\nprimarily of caring for the patient,\n (iii) physical, occupational or speech therapy if provided by the home\nhealth service or agency, and\n (iv) medical supplies, drugs and medications prescribed by a\nphysician, and laboratory services by or on behalf of a certified home\nhealth agency or licensed home care services agency to the extent such\nitems would have been covered or provided under the contract if the\ncovered person had been hospitalized or confined in a skilled nursing\nfacility as defined in subchapter XVIII of the Social Security Act, 42\nU.S.C. § 1395 et seq.\n (D) For the purpose of determining the benefits for home care\navailable to a covered person, each visit by a member of a home care\nteam shall be considered as one home care visit. The contract may\ncontain a limitation on the number of home care visits, but not less\nthan forty such visits in any calendar year or in any continuous period\nof twelve months, for each covered person. Four hours of home health\naide service shall be considered as one home care visit. Every contract\nissued by a hospital service corporation or health service corporation\nwhich provides coverage supplementing part A and part B of subchapter\nXVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make\navailable and, if requested by a subscriber holding a direct payment\ncontract or by all subscribers in a group remittance group or by the\ncontract holder in the case of group contracts issued pursuant to\nsection four thousand three hundred five of this article, provide\ncoverage of supplemental home care visits beyond those provided by part\nA and part B, sufficient to produce an aggregate coverage of three\nhundred sixty-five home care visits per contract year. Such coverage\nshall be provided pursuant to regulations prescribed by the\nsuperintendent. Written notice of the availability of such coverage\nshall be delivered to the group remitting agent or group contract holder\nprior to inception of such contract and annually thereafter, except that\nthis notice shall not be required where a policy covers two hundred or\nmore employees or where the benefit structure was the subject of\ncollective bargaining affecting persons who are employed in more than\none state.\n The provisions of this subsection shall not apply to a contract issued\npursuant to section four thousand three hundred five of this article\nwhich covers persons employed in more than one state or the benefit\nstructure of which was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n (b) Every contract issued by a medical expense indemnity corporation\nor a health service corporation which provides coverage for in-patient\nsurgical care shall include coverage for a second surgical opinion by a\nqualified physician on the need for surgery, except that this provision\nshall not apply to a contract issued pursuant to section four thousand\nthree hundred five of this article which covers persons employed in more\nthan one state or the benefit structure of which was the subject of\ncollective bargaining affecting persons who are employed in more than\none state.\n (c) (1) (A) Every contract issued by a corporation subject to the\nprovisions of this article which provides hospital service, medical\nexpense indemnity or both shall provide coverage for maternity care\nincluding hospital, surgical or medical care to the same extent that\nhospital service, medical expense indemnity or both are provided for\nillness or disease under the contract. Such maternity care coverage,\nother than coverage for perinatal complications, shall include inpatient\nhospital coverage for mother and for newborn for at least forty-eight\nhours after childbirth for any delivery other than a caesarean section,\nand for at least ninety-six hours following a caesarean section. Such\ncoverage for maternity care shall include the services of a midwife\nlicensed pursuant to article one hundred forty of the education law,\npracticing consistent with section sixty-nine hundred fifty-one of the\neducation law and affiliated or practicing in conjunction with a\nfacility licensed pursuant to article twenty-eight of the public health\nlaw, but no insurer shall be required to pay for duplicative routine\nservices actually provided by both a licensed midwife and a physician.\n (B) Maternity care coverage also shall include, at minimum, parent\neducation, assistance and training in breast or bottle feeding, and the\nperformance of any necessary maternal and newborn clinical assessments.\n (C) The mother shall have the option to be discharged earlier than the\ntime periods established in subparagraph (A) of this paragraph. In such\ncase, the inpatient hospital coverage must include at least one home\ncare visit, which shall be in addition to, rather than in lieu of, any\nhome health care coverage available under the contract. The contract\nmust cover the home care visit which may be requested at any time within\nforty-eight hours of the time of delivery (ninety-six hours in the case\nof caesarean section), and shall be delivered within twenty-four hours,\n(i) after discharge, or (ii) of the time of the mother's request,\nwhichever is later. Such home care coverage shall be pursuant to the\ncontract and subject to the provisions of this paragraph, and not\nsubject to deductibles, coinsurance or copayments.\n (2) Coverage provided under this subsection for care and treatment\nduring pregnancy shall include provision for not less than two payments,\nat reasonable intervals and for services rendered, for prenatal care and\na separate payment for the delivery and postnatal care provided.\n (d) (1) A hospital service corporation or a health service corporation\nwhich provides coverage for in-patient hospital care must make available\nand, if requested by a person holding a direct payment individual\ncontract or by all persons holding individual contracts in a group whose\npremiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide coverage for care in nursing\nhomes. Such coverage shall be made available at the inception of all new\ncontracts and, with respect to all other contracts, at any anniversary\ndate subject to evidence of insurability. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (2) For the purpose of this subsection, care in nursing homes shall\nmean the continued care and treatment of a covered person who is under\nthe care of a physician but only if (i) the care is provided in a\nnursing home as defined in section two thousand eight hundred one of the\npublic health law or a skilled nursing facility as defined in subchapter\nXVIII of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii)\nthe covered person has been in a hospital for at least three days\nimmediately preceding admittance to the nursing home or the skilled\nnursing facility, and (iii) further hospitalization would otherwise be\nnecessary. The aggregate of the number of covered days of care in a\nhospital and the number of covered days of care in a nursing home, with\ntwo days of care in a nursing home equivalent to one day of care in a\nhospital, need not exceed the number of covered days of hospital care\nprovided under the contract in a benefit period. The level of benefits\nto be provided for nursing home care must be reasonably related to the\nbenefits provided for hospital care.\n (e) (1) A hospital service corporation or a health service corporation\nwhich provides coverage for in-patient hospital care must make available\nand, if requested by a person holding a direct payment individual\ncontract or by all persons holding individual contracts in a group whose\npremiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide coverage for ambulatory care in\nhospital out-patient facilities, as a hospital is defined in section two\nthousand eight hundred one of the public health law, or subchapter XVIII\nof the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of\nthe availability of such coverage shall be delivered to the group\nremitting agent or group contract holder prior to inception of such\ncontract and annually thereafter, except that this notice shall not be\nrequired where a policy covers two hundred or more employees or where\nthe benefit structure was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n (2) For the purpose of this subsection, ambulatory care in hospital\nout-patient facilities shall mean services for diagnostic x-rays,\nlaboratory and pathological examinations, physical and occupational\ntherapy and radiation therapy, and services and medications used for\nnonexperimental cancer chemotherapy and cancer hormone therapy, provided\nthat such services and medications are (i) related to and necessary for\nthe treatment or diagnosis of the patient's illness or injury, (ii)\nordered by a physician and (iii) in the case of physical therapy,\nservices are to be furnished in connection with the same illness for\nwhich the patient had been hospitalized or in connection with surgical\ncare, but in no event need benefits for physical therapy be provided\nwhich commences more than six months after discharge from a hospital or\nthe date surgical care was rendered, and in no event need benefits for\nphysical therapy be provided after three hundred sixty-five days from\nthe date of discharge from a hospital or the date surgical care was\nrendered. Such coverage shall be made available at the inception of all\nnew contracts and, with respect to all other contracts, at any\nanniversary date subject to evidence of insurability.\n (f) (1) A medical expense indemnity corporation or a health service\ncorporation which provides coverage for physicians' services must make\navailable and, if requested by a person holding an individual direct\npayment contract or by all persons holding individual contracts in a\ngroup whose premiums are paid by a remitting agent or by the contract\nholder in the case of a group contract issued pursuant to section four\nthousand three hundred five of this article, provide coverage for\nambulatory care in physicians' offices. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (2) For the purpose of this subsection, ambulatory care in physicians'\noffices shall mean services for diagnostic x-rays, radiation therapy,\nlaboratory and pathological examinations, and services and medications\nused for nonexperimental cancer chemotherapy and cancer hormone therapy,\nprovided that such services and medications are (i) related to and\nnecessary for the treatment or diagnosis of the patient's illness or\ninjury, and (ii) ordered by a physician. Such coverage shall be made\navailable at the inception of all new contracts and, with respect to all\nother contracts at any anniversary date subject to evidence of\ninsurability.\n (g) (1) A hospital service corporation or a health service\ncorporation, which provides group, group remittance or school blanket\ncoverage for inpatient hospital care, shall provide as part of its\ncontract broad-based coverage for the diagnosis and treatment of mental,\nnervous or emotional disorders or ailments, however defined in such\ncontract, at least equal to the coverage provided for other health\nconditions and shall include:\n (A) benefits for in-patient care in a hospital as defined by\nsubdivision ten of section 1.03 of the mental hygiene law, which\nbenefits may be limited to not less than thirty days of active treatment\nin any contract year, plan year or calendar year.\n (B) benefits for out-patient care provided in a facility issued an\noperating certificate by the commissioner of mental health pursuant to\nthe provisions of article thirty-one of the mental hygiene law or in a\nfacility operated by the office of mental health, which benefits may be\nlimited to not less than twenty visits in any contract year, plan year\nor calendar year. Benefits for partial hospitalization program services\nshall be provided as an offset to covered inpatient days at a ratio of\ntwo partial hospitalization visits to one inpatient day of treatment.\n (C) Such coverage may be provided on a contract year, plan year or\ncalendar year basis and shall be consistent with the provision of other\nbenefits under the contract. Such coverage may be subject to annual\ndeductibles, co-pays and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the contract.\n (D) For the purpose of this subsection, "active treatment" means\ntreatment furnished in conjunction with in-patient confinement for\nmental, nervous or emotional disorders or ailments that meet such\nstandards as shall be prescribed pursuant to the regulations of the\ncommissioner of mental health.\n (E) In the event the group remittance group or contract holder is\nprovided coverage under this subsection and under paragraph one of\nsubsection (h) of this section from the same health service corporation,\nor under a contract that is jointly underwritten by two health service\ncorporations or by a health service corporation and a medical expense\nindemnity corporation, the aggregate of the benefits for outpatient care\nobtained under subparagraph (B) of this paragraph and paragraph one of\nsubsection (h) of this section may be limited to not less than twenty\nvisits in any contract year, plan year or calendar year.\n (2) (A) A hospital service corporation or a health service\ncorporation, which provides group, group remittance or school blanket\ncoverage for inpatient hospital care, shall provide comparable coverage\nfor adults and children with biologically based mental illness. Such\nhospital service corporation or health service corporation shall also\nprovide such comparable coverage for children with serious emotional\ndisturbances. Such coverage shall be provided under the terms and\nconditions otherwise applicable under the contract, including network\nlimitations or variations, exclusions, co-pays, coinsurance, deductibles\nor other specific cost sharing mechanisms. Provided further, where a\ncontract provides both in-network and out-of-network benefits, the\nout-of-network benefits may have different coinsurance, co-pays, or\ndeductibles, than the in-network benefits, regardless of whether the\ncontract is written under one license or two licenses.\n (B) For purposes of this subsection, the term "biologically based\nmental illness" means a mental, nervous, or emotional condition that is\ncaused by a biological disorder of the brain and results in a clinically\nsignificant, psychological syndrome or pattern that substantially limits\nthe functioning of the person with the illness. Such biologically based\nmental illnesses are defined as schizophrenia/psychotic disorders, major\ndepression, bipolar disorder, delusional disorders, panic disorder,\nobsessive compulsive disorders, anorexia, and bulimia.\n (3) For purposes of this subsection, the term "children with serious\nemotional disturbances" means persons under the age of eighteen years\nwho have diagnoses of attention deficit disorders, disruptive behavior\ndisorders, or pervasive development disorders, and where there are one\nor more of the following:\n (A) serious suicidal symptoms or other life-threatening\nself-destructive behaviors;\n (B) significant psychotic symptoms (hallucinations, delusion, bizarre\nbehaviors);\n (C) behavior caused by emotional disturbances that placed the child at\nrisk of causing personal injury or significant property damage; or\n (D) behavior caused by emotional disturbances that placed the child at\nsubstantial risk of removal from the household.\n (4) (A) The provisions of paragraph two of this subsection shall not\napply to any group remittance group or group contract holder with fifty\nor fewer employees who is a group remittance group or group contract\nholder of a policy that is subject to the provisions of this section;\nprovided however that a hospital service corporation or health service\ncorporation must make available, and if requested by such group\nremitting agent or group contract holder, provide the coverage as\nspecified in paragraph two of this subsection. Written notice of the\navailability of such coverage shall be delivered to the remitting agent\nor group contract holder prior to inception of such contract and\nannually thereafter.\n (B) The superintendent shall develop and implement a methodology to\ncover the cost to any such group contract holder for providing the\ncoverage required in paragraph one of this subsection. Such methodology\nshall be financed from moneys appropriated from the General Fund that\nshall be made available to the superintendent for such purposes, to the\nextent of funds available.\n (5)(A) Nothing in this subsection shall be construed to prevent the\nmedical management or utilization review of mental health benefits,\nincluding the use of prospective, concurrent or retrospective\nutilization review, preauthorization, and appropriateness criteria as to\nthe level and intensity of treatment applicable to behavioral health.\n (B) Nothing in this subsection shall be construed to prevent a\ncontract from providing services through a network of participating\nproviders who shall meet certain requirements for participation,\nincluding provider credentialing.\n (C) Nothing in this subsection shall be construed to require a\ncontract: (I) to cover mental health benefits or services for\nindividuals who are presently incarcerated, confined or committed to a\nlocal correctional facility or a prison, or a custodial facility for\nyouth operated by the office of children and family services; or (II) to\ncover services solely because such services are ordered by a court.\n (D) Nothing in this subsection shall be deemed to require a contract\nto cover benefits or services deemed cosmetic in nature on the grounds\nthat changing or improving an individual's appearance is justified by\nthe individual's mental health needs.\n (h) (1) A medical expense indemnity corporation or a health service\ncorporation, which provides group, group remittance or school blanket\ncoverage for physician services, shall provide as part of its contract\nbroad-based coverage for the diagnosis and treatment of mental, nervous\nor emotional disorders or ailments, however defined in such contract, at\nleast equal to the coverage provided for other health conditions and\nshall include: benefits for outpatient care provided by a psychiatrist\nor psychologist licensed to practice in this state, a licensed clinical\nsocial worker who meets the requirements of subsection (n) of this\nsection, or a professional corporation or university faculty practice\ncorporation thereof, which benefits may be limited to not less than\ntwenty visits in any contract year, plan year or calendar year. Such\ncoverage may be provided on a contract year, plan year or calendar year\nbasis and shall be consistent with the provision of other benefits under\nthe contract. Such coverage may be subject to annual deductibles,\nco-pays and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the contract. In the event the group remittance group or\ncontract holder is provided coverage provided under this paragraph and\nunder subparagraph (B) of paragraph one of subsection (g) of this\nsection from the same health service corporation, or under a contract\nwhich is jointly underwritten by two health service corporations or by a\nhealth service corporation and a medical expense indemnity corporation,\nthe aggregate of the benefits for out-patient care obtained under\nsubparagraph (B) of paragraph one of subsection (g) of this section and\nthis paragraph may be limited to not less than twenty visits in any\ncontract year, plan year or calendar year.\n (2) (A) A medical expense indemnity corporation or a health service\ncorporation, which provides group, group remittance or school blanket\ncoverage for physician services, shall provide comparable coverage for\nadults and children with biologically based mental illness. Such medical\nexpense indemnity corporation or health service corporation shall also\nprovide such comparable coverage for children with serious emotional\ndisturbances. Such coverage shall be provided under the terms and\nconditions otherwise applicable under the contract, including network\nlimitations or variations, exclusions, co-pays, coinsurance, deductibles\nor other specific cost sharing mechanisms. Provided further, where a\ncontract provides both in-network and out-of-network benefits, the\nout-of-network benefits may have different coinsurance, co-pays, or\ndeductibles, than the in-network benefits, regardless of whether the\ncontract is written under one license or two licenses.\n (B) For purposes of this subsection, the term "biologically based\nmental illness" means a mental, nervous, or emotional condition that is\ncaused by a biological disorder of the brain and results in a clinically\nsignificant, psychological syndrome or pattern that substantially limits\nthe functioning of the person with the illness. Such biologically based\nmental illnesses are defined as schizophrenia/psychotic disorders, major\ndepression, bipolar disorder, delusional disorders, panic disorder,\nobsessive compulsive disorder, anorexia, and bulimia.\n (3) For purposes of this subsection, the term "children with serious\nemotional disturbances" means persons under the age of eighteen years\nwho have diagnoses of attention deficit disorders, disruptive behavior\ndisorders, or pervasive development disorders, and where there are one\nor more of the following:\n (A) serious suicidal symptoms or other life-threatening\nself-destructive behaviors;\n (B) significant psychotic symptoms (hallucinations, delusion, bizarre\nbehaviors);\n (C) behavior caused by emotional disturbances that placed the child at\nrisk of causing personal injury or significant property damage; or\n (D) behavior caused by emotional disturbances that placed the child at\nsubstantial risk of removal from the household.\n (4) (A) The provisions of paragraph two of this subsection shall not\napply to any group remittance group or group contract holder with fifty\nor fewer employees who is a group remittance group or group contract\nholder of a contract that is subject to the provisions of this section;\nprovided, however, that a hospital service corporation or health service\ncorporation must make available, and if requested by such group\nremitting agent or group contract holder, provide the coverage as\nspecified in paragraph two of this subsection. Written notice of the\navailability of the coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter.\n (B) The superintendent shall develop and implement a methodology to\ncover the cost to any such group remittance group and group contract\nholder for providing the coverage required in paragraph one of this\nsubsection. Such methodology shall be financed from moneys appropriated\nfrom the General Fund that shall be made available to the superintendent\nfor such purposes, to the extent of funds available.\n (5)(A) Nothing in this subsection shall be construed to prevent the\nmedical management or utilization review of mental health benefits,\nincluding the use of prospective, concurrent or retrospective\nutilization review, preauthorization, and appropriateness criteria as to\nthe level and intensity of treatment applicable to behavioral health.\n (B) Nothing in this subsection shall be construed to prevent a\ncontract from providing services through a network of participating\nproviders who shall meet certain requirements for participation,\nincluding provider credentialing.\n (C) Nothing in this subsection shall be construed to require a\ncontract: (I) to cover mental health benefits or services for\nindividuals who are presently incarcerated, confined or committed to a\nlocal correctional facility or a prison, or a custodial facility for\nyouth operated by the office of children and family services; or (II) to\ncover services solely because such services are ordered by a court.\n (D) Nothing in this subsection shall be deemed to require a contract\nto cover benefits or services deemed cosmetic in nature on the grounds\nthat changing or improving an individual's appearance is justified by\nthe individual's mental health needs.\n (i) A medical expense indemnity corporation or health service\ncorporation which provides coverage for physicians, psychiatrists or\npsychologists for psychiatric or psychological services or for the\ndiagnosis and treatment of mental, nervous or emotional disorders and\nailments, however defined in such contract, must make available and if\nrequested by all persons holding individual contracts in a group whose\npremiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide the same coverage for such\nservices when performed by a licensed clinical social worker, within the\nlawful scope of his or her practice, who is licensed pursuant to article\none hundred fifty-four of the education law. The state board for social\nwork shall maintain a list of all licensed clinical social workers\nqualified for reimbursement under this subsection. Such coverage shall\nbe made available at the inception of all new contracts and, with\nrespect to all other contracts, at any anniversary date subject to\nevidence of insurability. Written notice of the availability of such\ncoverage shall be delivered to the group remitting agent or group\ncontract holder prior to inception of such contract and annually\nthereafter, except that this notice shall not be required where a policy\ncovers two hundred or more employees or where the benefit structure was\nthe subject of collective bargaining affecting persons who are employed\nin more than one state.\n (j)(1) A health service corporation or medical expense indemnity\ncorporation that provides medical, major-medical or similar\ncomprehensive-type coverage shall provide coverage for the provision of\npreventive and primary care services.\n (2) For purposes of this paragraph and paragraph one of this\nsubsection, preventive and primary care services shall mean the\nfollowing services rendered to a covered child of a subscriber from the\ndate of birth through the attainment of nineteen years of age:\n (A) an initial hospital check-up and well-child visits scheduled in\naccordance with the prevailing clinical standards of a national\nassociation of pediatric physicians designated by the commissioner of\nhealth (except for any standard that would limit the specialty or forum\nof licensure of the practitioner providing the service other than the\nlimits under state law). Coverage for such services rendered shall be\nprovided only to the extent that such services are provided by or under\nthe supervision of a physician, or other professional licensed under\narticle one hundred thirty-nine of the education law whose scope of\npractice pursuant to such law includes the authority to provide the\nspecified services. Coverage shall be provided for such services\nrendered in a hospital, as defined in section twenty-eight hundred one\nof the public health law, or in an office of a physician or other\nprofessional licensed under article one hundred thirty-nine of the\neducation law whose scope of practice pursuant to such law includes the\nauthority to provide the specified services,\n (B) at each visit, services in accordance with the prevailing clinical\nstandards of such designated association, including a medical history, a\ncomplete physical examination, developmental assessment, anticipatory\nguidance, appropriate immunizations and laboratory tests which tests are\nordered at the time of the visit and performed in the practitioner's\noffice, as authorized by law, or in a clinical laboratory, and\n (C) necessary immunizations, as determined by the superintendent in\nconsultation with the commissioner of health, consisting of at least\nadequate dosages of vaccine against diphtheria, pertussis, tetanus,\npolio, measles, rubella, mumps, haemophilus influenzae type b and\nhepatitis b, which meet the standards approved by the United States\npublic health service for such biological products.\n (D) Such coverage required pursuant to this paragraph and paragraph\none of this subsection shall not be subject to annual deductibles or\ncoinsurance.\n (E) Such coverage required pursuant to this paragraph and paragraph\none of this subsection shall not restrict or eliminate existing coverage\nprovided by the contract.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides hospital, surgical or medical care coverage,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following preventive care and\nscreenings for subscribers, and such coverage shall not be subject to\nannual deductibles or coinsurance:\n (A) evidence-based items or services for preventive care and\nscreenings that have in effect a rating of 'A' or 'B' in the current\nrecommendations of the United States preventive services task force;\n (B) immunizations that have in effect a recommendation from the\nadvisory committee on immunization practices of the centers for disease\ncontrol and prevention with respect to the individual involved;\n (C) with respect to children, including infants and adolescents,\nevidence-informed preventive care and screenings provided for in\ncomprehensive guidelines supported by the health resources and services\nadministration; and\n (D) with respect to women, such additional preventive care and\nscreenings not described in subparagraph (A) of this paragraph and as\nprovided for in comprehensive guidelines supported by the health\nresources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n (k) (1) Every contract that provides hospital, major medical or\nsimilar comprehensive coverage must provide inpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such coverage shall not\napply financial requirements or treatment limitations to inpatient\nsubstance use disorder benefits that are more restrictive than the\npredominant financial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the contract.\nFurther, such coverage shall be provided consistent with the federal\nPaul Wellstone and Pete Domenici Mental Health Parity and Addiction\nEquity Act of 2008 (29 U.S.C. § 1185a).\n (2) Coverage provided under this subsection may be limited to\nfacilities in New York state which are certified by the office of\nalcoholism and substance abuse services and, in other states, to those\nwhich are accredited by the joint commission as alcoholism, substance\nabuse, or chemical dependence treatment programs.\n (3) Coverage provided under this subsection may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven contract.\n (l) (1) Every contract that provides medical, major medical or similar\ncomprehensive-type coverage must provide outpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such coverage shall not\napply financial requirements or treatment limitations to outpatient\nsubstance use disorder benefits that are more restrictive than the\npredominant financial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the contract.\nFurther, such coverage shall be provided consistent with the federal\nPaul Wellstone and Pete Domenici Mental Health Parity and Addiction\nEquity Act of 2008 (29 U.S.C. § 1185a).\n (2) Coverage under this subsection may be limited to facilities in New\nYork state certified by the office of alcoholism and substance abuse\nservices or licensed by such office as outpatient clinics or medically\nsupervised ambulatory substance abuse programs and, in other states, to\nthose which are accredited by the joint commission as alcoholism or\nchemical dependence substance abuse treatment programs.\n (3) Coverage provided under this subsection may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven contract.\n (4) A contract providing coverage for substance use disorder services\npursuant to this subsection shall provide up to twenty outpatient visits\nper contract or calendar year to an individual who identifies him or\nherself as a family member of a person suffering from substance use\ndisorder and who seeks treatment as a family member who is otherwise\ncovered by the applicable contract pursuant to this subsection. The\ncoverage required by this subsection shall include treatment as a family\nmember pursuant to such family member's own contract provided such\nfamily member:\n (A) does not exceed the allowable number of family visits provided by\nthe applicable contract pursuant to this subsection; and\n (B) is otherwise entitled to coverage pursuant to this subsection and\nsuch family member's applicable contract.\n (m) A medical expense indemnity corporation or a health service\ncorporation which provides coverage for any service within the lawful\nscope of practice of a duly licensed registered professional nurse must\nmake available, and if requested by all subscribers in a group\nremittance group, or by a contract holder in the case of a group\ncontract issued pursuant to section four thousand three hundred five of\nthis chapter, provide reimbursement for such services when performed by\na duly licensed registered professional nurse provided, however, that\nreimbursement shall not be made for nursing services provided to a\nsubscriber in a general hospital, nursing home, or a facility providing\nhealth related services, as such terms are defined in section\ntwenty-eight hundred one of the public health law, or in a facility, as\nsuch term is defined in subdivision six of section 1.03 of the mental\nhygiene law, or in a physician's office. Such coverage may be subject to\nannual deductibles and co-insurance as may be deemed appropriate by the\nsuperintendent and are consistent with those imposed on other benefits\nwithin a given policy. Such coverage shall not replace, restrict or\neliminate existing coverage provided by the policy. Coverage for the\nservices of a duly licensed registered professional nurse need be\nprovided only if the nature of the patient's illness or condition\nrequires nursing care which can appropriately be provided by a person\nwith the education and professional skill of a registered professional\nnurse and the nursing care is necessary in the treatment of the\npatient's illness or condition. Written notice of the availability of\nsuch coverage shall be delivered to the group remitting agent or group\ncontract holder prior to inception of such contract and annually\nthereafter, except that this notice shall not be required where a policy\ncovers two hundred or more employees or where the benefit structure was\nthe subject of collective bargaining affecting persons who are employed\nin more than one state.\n (n) In addition to the requirements of subsection (i) of this section,\nevery health service or medical expense indemnity corporation issuing a\ngroup contract pursuant to this section or a group remittance contract\nfor delivery in this state which contract provides reimbursement to\nsubscribers or physicians, psychiatrists or psychologists for\npsychiatric or psychological services or for the diagnosis and treatment\nof mental, nervous or emotional disorders and ailments, however defined\nin such contract, must provide the same coverage to persons covered\nunder the group contract for such services when performed by a licensed\nclinical social worker, within the lawful scope of his or her practice,\nwho is licensed pursuant to subdivision two of section seven thousand\nseven hundred four of the education law and in addition shall have\neither (i) three or more additional years experience in psychotherapy,\nwhich for the purposes of this subsection shall mean the use of verbal\nmethods in interpersonal relationships with the intent of assisting a\nperson or persons to modify attitudes and behavior which are\nintellectually, socially or emotionally maladaptive, under supervision,\nsatisfactory to the state board for social work, in a facility, licensed\nor incorporated by an appropriate governmental department, providing\nservices for diagnosis or treatment of mental, nervous or emotional\ndisorders or ailments, or (ii) three or more additional years experience\nin psychotherapy under the supervision, satisfactory to the state board\nfor social work, of a psychiatrist, a licensed and registered\npsychologist or a licensed clinical social worker qualified for\nreimbursement pursuant to subsection (i) of this section, or (iii) a\ncombination of the experience specified in paragraphs (i) and (ii)\ntotaling three years, satisfactory to the state board for social work.\nThe state board for social work shall maintain a list of all licensed\nclinical social workers qualified for reimbursement under this\nsubsection.\n (o) A hospital service corporation or a health service corporation\nwhich provides coverage for inpatient hospital care must make available\nand, if requested by all persons holding individual contracts in a group\nwhose premiums are paid by a remitting agent or by the contractholder in\nthe case of a group contract issued pursuant to section four thousand\nthree hundred five of this article, provide coverage for hospice care.\nFor the purposes of this subsection, hospice care shall mean the care\nand treatment of a covered person who has been certified by such\nperson's primary attending physician as having a life expectancy of six\nmonths or less and which is provided by a hospice organization certified\npursuant to article forty of the public health law or under a similar\ncertification process required by the state in which the hospice\norganization is located. Hospice care coverage shall be at least equal\nto: (1) a total of two hundred ten days of coverage beginning with the\nfirst day on which care is provided, for inpatient hospice care in a\nhospice or in a hospital and home care and outpatient services provided\nby the hospice, including drugs and medical supplies, and (2) five\nvisits for bereavement counseling services, either before or after the\ninsured's death, provided to the family of the terminally ill insured.\nSuch coverage shall be made available at the inception of all new\ncontracts and, with respect to contracts issued before the effective\ndate of this provision, at the first annual anniversary date thereafter,\nwithout evidence of insurability and at any subsequent annual\nanniversary date subject to evidence of insurability. Such coverage may\nbe subject to annual deductibles and coinsurance as may be deemed\nappropriate by the superintendent and are consistent with those imposed\non other benefits within a given contract period. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (p) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation that provides coverage for\nhospital, surgical or medical care shall provide the following coverage\nfor mammography screening for occult breast cancer:\n (A) upon the recommendation of a physician, a mammogram at any age for\ncovered persons having a prior history of breast cancer or who have a\nfirst degree relative with a prior history of breast cancer;\n (B) a single baseline mammogram for covered persons aged thirty-five\nthrough thirty-nine, inclusive; and\n (C) an annual mammogram for covered persons aged forty and older.\n (D) The coverage required in this paragraph or paragraph two of this\nsubsection may be subject to annual deductibles and coinsurance as may\nbe deemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given contract.\n (2) For purposes of paragraph one of this subsection, mammography\nscreening means an X-ray examination of the breast using dedicated\nequipment, including X-ray tube, filter, compression device, screens,\nfilms and cassettes, with an average glandular radiation dose less than\n0.5 rem per view per breast.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides coverage for hospital, surgical or medical care,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following mammography\nscreening services, and such coverage shall not be subject to annual\ndeductibles or coinsurance:\n (A) evidence-based items or services for mammography that have in\neffect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n (B) with respect to women, such additional preventive care and\nscreenings for mammography not described in subparagraph (A) of this\nparagraph and as provided for in comprehensive guidelines supported by\nthe health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n (q) (1) Every policy issued by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation which provides coverage for prescribed drugs approved by the\nfood and drug administration of the United States government for the\ntreatment of certain types of cancer shall not exclude coverage of any\nsuch drug on the basis that such drug has been prescribed for the\ntreatment of a type of cancer for which the drug has not been approved\nby the food and drug administration. Provided, however, that such drug\nmust be recognized for treatment of the specific type of cancer for\nwhich the drug has been prescribed in one of the following established\nreference compendia:\n (i) the American Hospital Formulary Service-Drug Information\n(AHFS-DI);\n (ii) National Comprehensive Cancer Networks Drugs and Biologics\nCompendium;\n (iii) Thomson Micromedex DrugDex;\n (iv) Elsevier Gold Standard's Clinical Pharmacology; or other\nauthoritative compendia as identified by the Federal Secretary of Health\nand Human Services or the Centers for Medicare & Medicaid Services\n(CMS); or recommended by review article or editorial comment in a major\npeer reviewed professional journal.\n (2) Notwithstanding the provisions of this subsection, coverage shall\nnot be required for any experimental or investigational drugs or any\ndrug which the food and drug administration has determined to be\ncontraindicated for treatment of the specific type of cancer for which\nthe drug has been prescribed. The provisions of this subsection shall\napply to cancer drugs only and nothing herein shall be construed to\ncreate, impair, alter, limit, modify, enlarge, abrogate or prohibit\nreimbursement for drugs used in the treatment of any other disease or\ncondition.\n (q-1) (1) Every contract issued by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation for delivery in this state that provides medical, major\nmedical or similar comprehensive-type coverage and provides coverage for\nprescription drugs and for cancer chemotherapy treatment shall provide\ncoverage for prescribed, orally administered anticancer medications used\nto kill or slow the growth of cancerous cells. Such coverage may be\nsubject to co-pays, coinsurance or deductibles, provided that the\nco-pays, coinsurance or deductibles are at least as favorable to an\ninsured as the co-pays, coinsurance or deductibles that apply to\ncoverage for intravenous or injected anticancer medications.\n (2) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n (A) vary the terms of the contract for the purpose or with the effect\nof avoiding compliance with this paragraph;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n (C) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n (E) achieve compliance with this paragraph by imposing an increase in\ncost sharing for an intravenous or injected anticancer medication.\n (r) Consistent with federal law, a hospital service corporation or a\nhealth service corporation which provides coverage supplementing part A\nand part B of subchapter XVIII of the federal Social Security Act, 42\nUSC §§ 1395 et seq., shall make available and, if requested by a person\nholding a direct payment individual contract or by all persons holding\nindividual contracts in a group whose premiums are paid by a remitting\nagent or by a contract holder in the case of a group contract issued\npursuant to section four thousand three hundred five of this article,\nprovide coverage for at least ninety days of care in a nursing home as\ndefined in section twenty-eight hundred one of the public health law,\nexcept when such coverage would duplicate coverage that is available\nunder the aforementioned subchapter XVIII. Such coverage shall be made\navailable at the inception of all new contracts and, with respect to all\nother contracts at each anniversary date of the contract.\n (1) Coverage shall be subject to a copayment of twenty-five dollars\nper day.\n (2) Brochures describing such coverage must be provided at the time of\napplication for all new contracts and thereafter on each anniversary\ndate of the contract, and with respect to all other contracts annually\nat each anniversary date of the contract. Such brochures must be\napproved by the superintendent in consultation with the commissioner of\nhealth.\n Such insurers shall report to the superintendent each year the number\nof contract holders to whom such insurers have issued such policies for\nnursing home coverage and the approximate number of persons covered by\nsuch policies.\n (3) The commensurate rate for the coverage must be approved by the\nsuperintendent.\n * (s) (1) A hospital service corporation or health service corporation\nwhich provides coverage for hospital care shall not exclude coverage for\nhospital care for diagnosis and treatment of correctable medical\nconditions otherwise covered by the policy solely because the medical\ncondition results in infertility; provided, however that:\n (A) subject to the provisions of paragraph three of this subsection,\nin no case shall such coverage exclude surgical or medical procedures\nprovided as part of such hospital care which would correct malformation,\ndisease or dysfunction resulting in infertility; and\n (B) provided, further however, that subject to the provisions of\nparagraph three of this subsection, in no case shall such coverage\nexclude diagnostic tests and procedures provided as part of such\nhospital care that are necessary to determine infertility or that are\nnecessary in connection with any surgical or medical treatments or\nprescription drug coverage provided pursuant to this subsection,\nincluding such diagnostic tests and procedures as hysterosalpingogram,\nhysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post\ncoital tests, testis biopsy, semen analysis, blood tests and ultrasound;\nand\n (C) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with paragraph three of this subsection.\n (2) A medical expense indemnity or health service corporation which\nprovides coverage for surgical and medical care shall not exclude\ncoverage for surgical and medical care for diagnosis and treatment of\ncorrectable medical conditions otherwise covered by the policy solely\nbecause the medical condition results in infertility; provided, however\nthat:\n (A) subject to the provisions of paragraph three of this subsection,\nin no case shall such coverage exclude surgical or medical procedures\nwhich would correct malformation, disease or dysfunction resulting in\ninfertility; and\n (B) provided, further however, that subject to the provisions of\nparagraph three of this subsection, in no case shall such coverage\nexclude diagnostic tests and procedures that are necessary to determine\ninfertility or that are necessary in connection with any surgical or\nmedical treatments or prescription drug coverage provided pursuant to\nthis subsection, including such diagnostic tests and procedures as\nhysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,\nsono-hysterogram, post coital tests, testis biopsy, semen analysis,\nblood tests and ultrasound; and\n (C) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with paragraph three of this subsection.\n (3) Coverage of diagnostic and treatment procedures, including\nprescription drugs used in the diagnosis and treatment of infertility as\nrequired by paragraphs one and two of this subsection shall be provided\nin accordance with this paragraph.\n (A) Coverage shall be provided for persons whose ages range from\ntwenty-one through forty-four years, provided that nothing herein shall\npreclude the provision of coverage to persons whose age is below or\nabove such range.\n (B) Diagnosis and treatment of infertility shall be prescribed as part\nof a physician's overall plan of care and consistent with the guidelines\nfor coverage as referenced in this paragraph.\n (C) Coverage may be subject to co-payments, coinsurance and\ndeductibles as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy.\n (D) Coverage shall be limited to those individuals who have been\npreviously covered under the policy for a period of not less than twelve\nmonths, provided that for the purposes of this paragraph "period of not\nless than twelve months" shall be determined by calculating such time\nfrom either the date the insured was first covered under the existing\npolicy or from the date the insured was first covered by a previously\nin-force converted policy, whichever is earlier.\n (E) Coverage shall not be required to include the diagnosis and\ntreatment of infertility in connection with: (i) in vitro fertilization,\ngamete intrafallopian tube transfers or zygote intrafallopian tube\ntransfers; (ii) the reversal of elective sterilizations; (iii) sex\nchange procedures; (iv) cloning; or (v) medical or surgical services or\nprocedures that are deemed to be experimental in accordance with\nclinical guidelines referenced in subparagraph (F) of this paragraph.\n (F) The superintendent, in consultation with the commissioner of\nhealth, shall promulgate regulations which shall stipulate the\nguidelines and standards which shall be used in carrying out the\nprovisions of this paragraph, which shall include:\n (i) The determination of "infertility" in accordance with the\nstandards and guidelines established and adopted by the American College\nof Obstetricians and Gynecologists and the American Society for\nReproductive Medicine;\n (ii) The identification of experimental procedures and treatments not\ncovered for the diagnosis and treatment of infertility determined in\naccordance with the standards and guidelines established and adopted by\nthe American College of Obstetricians and Gynecologists and the American\nSociety for Reproductive Medicine;\n (iii) The identification of the required training, experience and\nother standards for health care providers for the provision of\nprocedures and treatments for the diagnosis and treatment of infertility\ndetermined in accordance with the standards and guidelines established\nand adopted by the American College of Obstetricians and Gynecologists\nand the American Society for Reproductive Medicine; and\n (iv) The determination of appropriate medical candidates by the\ntreating physician in accordance with the standards and guidelines\nestablished and adopted by the American College of Obstetricians and\nGynecologists and/or the American Society for Reproductive Medicine.\n (4) Every contract issued by a medical expense indemnity corporation,\na hospital service corporation or a health services corporation that\nprovides coverage for prescription fertility drugs and requires or\npermits prescription drugs to be purchased through a network\nparticipating mail order or other non-retail pharmacy shall provide the\nsame coverage for prescription fertility drugs when such drugs are\npurchased from a network participating non-mail order retail pharmacy\nprovided that the network participating non-mail order retail pharmacy\nagrees in advance, through a contractual network agreement, to the same\nreimbursement amount, as well as the same applicable terms and\nconditions, that the corporation has established for the network\nparticipating mail order or other non-retail pharmacy. In such case, the\ncontract shall not impose any fee, co-payment, co-insurance, deductible\nor other condition on any covered person who does not elect to purchase\nprescription fertility drugs through a network participating mail order\nor other non-retail pharmacy; provided, however, that the provisions of\nthis section shall not supersede the terms of a collective bargaining\nagreement or apply to a contract that is the result of a collective\nbargaining agreement between an employer and a recognized or certified\nemployee organization.\n * NB There are 2 sb (s)'s\n * (s) Notwithstanding any provision of a contract issued by a medical\nexpense indemnity corporation, a dental expense indemnity corporation or\nhealth service corporation, every contract which provides coverage for\ncare provided through licensed health professionals who can bill for\nservices shall provide the same coverage and reimbursement for such\nservice provided pursuant to a clinical practice plan established\npursuant to subdivision fourteen of section two hundred six of the\npublic health law.\n * NB There are 2 sb (s)'s\n (t) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation that provides coverage for\nhospital, surgical, or medical care shall provide coverage for an annual\ncervical cytology screening for cervical cancer and its precursor states\nfor women aged eighteen and older. Such coverage required by this\nparagraph may be subject to annual deductibles and coinsurance as may be\ndeemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given contract.\n (2) For purposes of paragraph one of this subsection, cervical\ncytology screening shall include an annual pelvic examination,\ncollection and preparation of a Pap smear, and laboratory and diagnostic\nservices provided in connection with examining and evaluating the Pap\nsmear.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides coverage for hospital, surgical or medical care,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following cervical cytology\nscreening services, and such coverage shall not be subject to annual\ndeductibles or coinsurance:\n (A) evidence-based items or services for cervical cytology that have\nin effect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n (B) with respect to women, such additional preventive care and\nscreenings for cervical cytology not described in subparagraph (A) of\nthis paragraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n (u) (1) A medical expense indemnity corporation or a health service\ncorporation which provides medical coverage that includes coverage for\nphysician services in a physician's office and every policy which\nprovides major medical or similar comprehensive-type coverage shall\ninclude coverage for the following equipment and supplies for the\ntreatment of diabetes, if recommended or prescribed by a physician or\nother licensed health care provider legally authorized to prescribe\nunder title eight of the education law: blood glucose monitors and blood\nglucose monitors for the visually impaired, data management systems,\ntest strips for glucose monitors and visual reading and urine testing\nstrips, insulin, injection aids, cartridges for the visually impaired,\nsyringes, insulin pumps and appurtenances thereto, insulin infusion\ndevices, and oral agents for controlling blood sugar. In addition, the\ncommissioner of the department of health shall provide and periodically\nupdate by rule or regulation a list of additional diabetes equipment and\nrelated supplies such as are medically necessary for the treatment of\ndiabetes, for which there shall also be coverage. Such policies shall\nalso include coverage for diabetes self-management education to ensure\nthat persons with diabetes are educated as to the proper self-management\nand treatment of their diabetic condition, including information on\nproper diets. Such coverage for self-management education and education\nrelating to diet shall be limited to visits medically necessary upon the\ndiagnosis of diabetes, where a physician diagnoses a significant change\nin the patient's symptoms or conditions which necessitate changes in a\npatient's self-management, or where reeducation or refresher education\nis necessary. Such education may be provided by the physician or other\nlicensed health care provider legally authorized to prescribe under\ntitle eight of the education law, or their staff, as part of an office\nvisit for diabetes diagnosis or treatment, or by a certified diabetes\nnurse educator, certified nutritionist, certified dietitian or\nregistered dietitian upon the referral of a physician or other licensed\nhealth care provider legally authorized to prescribe under title eight\nof the education law. Education provided by the certified diabetes nurse\neducator, certified nutritionist, certified dietitian or registered\ndietitian may be limited to group settings wherever practicable.\nCoverage for self-management education and education relating to diet\nshall also include home visits when medically necessary.\n (2) Such coverage may be subject to annual deductibles and coinsurance\nas may be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy.\n (3) This subsection shall not apply to a policy which covers persons\nemployed in more than one state or the benefit structure of which was\nthe subject of collective bargaining affecting persons employed in more\nthan one state unless such policy is issued under the New York state\nhealth insurance plan established under article eleven of the civil\nservice law or issued to or through a local government.\n (u-1) A medical expense indemnity corporation or a health service\ncorporation which provides medical coverage that includes coverage for\nphysician services in a physician's office and every policy which\nprovides major medical or similar comprehensive-type coverage shall\ninclude coverage for equipment and supplies used for the treatment of\nostomies, if prescribed by a physician or other licensed health care\nprovider legally authorized to prescribe under title eight of the\neducation law. Such coverage shall be subject to annual deductibles and\ncoinsurance as deemed appropriate by the superintendent. The coverage\nrequired by this subsection shall be identical to, and shall not enhance\nor increase the coverage required as part of essential health benefits\nas required pursuant to section 2707(a) of the public health services\nact 42 U.S.C. 300 gg-6(a).\n (v) (1) Every contract issued by a medical expense indemnity\ncorporation, hospital service corporation or health service corporation\nwhich provides coverage for inpatient hospital care shall provide such\ncoverage for such period as is determined by the attending physician in\nconsultation with the patient to be medically appropriate after such\ncovered person has undergone a lymph node dissection or a lumpectomy for\nthe treatment of breast cancer or a mastectomy covered by the contract.\nSuch coverage may be subject to annual deductibles and coinsurance as\nmay be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy. Written\nnotice of the availability of such coverage shall be delivered to the\ngroup remitting agent or group contract holder prior to the inception of\nsuch contract and annually thereafter.\n (2) A medical expense indemnity corporation, hospital service\ncorporation or health service corporation which provides coverage under\nthis subsection and any participating entity through which the insurer\noffers health services shall not:\n (A) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the contract or vary the\nterms of the contract for the purpose or with the effect of avoiding\ncompliance with this subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this subsection;\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection; or\n (E) restrict coverage for any portion of a period within a hospital\nlength of stay required under this subsection in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n (3) The prohibitions in paragraph two of this subsection shall be in\naddition to the provisions of sections four thousand three hundred\nseventeen and four thousand three hundred eighteen of this article and\nnothing in this paragraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (w)(1) Every contract issued by a medical expense indemnity\ncorporation or health service corporation which provides medical, major\nmedical, or similar comprehensive-type coverage must provide coverage\nfor a second medical opinion by an appropriate specialist, including but\nnot limited to a specialist affiliated with a specialty care center for\nthe treatment of cancer, in the event of a positive or negative\ndiagnosis of cancer or a recurrence of cancer or a recommendation of a\ncourse of treatment for cancer, subject to the following:\n (i) In the case of a contract that requires, or provides financial\nincentives for, the covered person to receive covered services from\nhealth care providers participating in a provider network maintained by\nor under contract with the corporation, the contract shall include\ncoverage for a second medical opinion from a non-participating\nspecialist, including but not limited to a specialist affiliated with a\nspecialty care center for the treatment of cancer, when the attending\nphysician provides a written referral to a non-participating specialist,\nat no additional cost to the covered person beyond what such covered\nperson would have paid for services from a participating appropriate\nspecialist. Provided however that nothing herein shall impair the\ncovered person's rights (if any) under the contract to obtain the second\nmedical opinion from a non-participating specialist without a written\nreferral, subject to the payment of additional coinsurance (if any)\nrequired by the contract for services provided by non-participating\nproviders. The corporation shall compensate the non-participating\nspecialist at the usual, customary and reasonable rate, or at a rate\nlisted on a fee schedule filed and approved by the superintendent which\nprovides a comparable level of reimbursement.\n (ii) In the case of a contract that does not provide financial\nincentives for, and does not require, the covered person to receive\ncovered services from health care providers participating in a provider\nnetwork maintained by or under contract with the corporation, the\ncontract shall include coverage for a second medical opinion from a\nspecialist at no additional cost to the covered person beyond what the\ncovered person would have paid for comparable services covered under the\ncontract.\n (iii) Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\ncontract and, where applicable, consistent with the provisions of\nsubparagraphs (i) and (ii) of this paragraph.\n Nothing in this subsection shall eliminate or diminish the\ncorporation's obligation to comply with the provisions of section four\nthousand eight hundred four of this chapter and section forty-four\nhundred three of the public health law where applicable. Written notice\nof the availability of such coverage shall be delivered to the group\nremitting agent or group contract holder prior to the inception of such\ncontract and annually thereafter.\n (2) A medical expense indemnity corporation or health service\ncorporation which provides coverage under this subsection and any\nparticipating entity through which the insurer offers health services\nshall not:\n (A) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the contract or vary the\nterms of the contract for the purpose or with the effect of avoiding\ncompliance with this subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this subsection; or\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection.\n (3) The prohibitions in paragraph two of this subsection shall be in\naddition to the provisions of sections four thousand three hundred\nseventeen and four thousand three hundred eighteen of this article and\nnothing in this paragraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (x)(1) Every contract issued by a medical expense indemnity\ncorporation, hospital service corporation or health service corporation\nwhich provides coverage for surgical or medical care shall provide the\nfollowing coverage for breast reconstruction surgery after a mastectomy\nor partial mastectomy:\n (A) all stages of reconstruction of the breast on which the mastectomy\nor partial mastectomy has been performed; and\n (B) surgery and reconstruction of the other breast to produce a\nsymmetrical appearance;\nin the manner determined by the attending physician and the patient to\nbe appropriate. Such coverage may be subject to annual deductibles or\ncoinsurance provisions as may be deemed appropriate by the\nsuperintendent and as are consistent with those established for other\nbenefits within a given policy. Written notice of the availability of\nsuch coverage shall be delivered to the group remitting agent or group\ncontract holder prior to the inception of such contract and annually\nthereafter.\n (2) A medical expense indemnity corporation, hospital service\ncorporation or health service corporation which provides coverage under\nthis subsection and any participating entity through which the insurer\noffers health services shall not:\n (A) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this subsection;\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the affect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection;\n (E) restrict coverage for any portion of a period within a hospital\nlength of stay required under this subsection in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay; or\n (F) the prohibitions in this paragraph shall be in addition to the\nprovisions of sections four thousand three hundred seventeen and four\nthousand three hundred eighteen of this article and nothing in this\nparagraph shall be construed to suspend, supersede, amend or otherwise\nmodify such sections.\n * (y) Every contract which provides coverage for prescription drugs\nshall include coverage for the cost of enteral formulas for home use,\nwhether administered orally or via tube feeding, for which a physician\nor other licensed health care provider legally authorized to prescribe\nunder title eight of the education law has issued a written order. Such\nwritten order shall state that the enteral formula is clearly medically\nnecessary and has been proven effective as a disease-specific treatment\nregimen for those individuals who are or will become malnourished or\nsuffer from disorders, which if left untreated, cause chronic\ndisability, mental retardation or death. Specific diseases for which\nenteral formulas have been proven effective shall include, but are not\nlimited to, inherited diseases of amino-acid or organic acid metabolism;\nCrohn's Disease; gastroesophageal reflux with failure to thrive;\ndisorders of gastrointestinal motility such as chronic intestinal\npseudo-obstruction; and multiple, severe food allergies which if left\nuntreated will cause malnourishment, chronic physical disability, mental\nretardation or death. Enteral formulas which are medically necessary and\ntaken under written order from a physician for the treatment of specific\ndiseases shall be distinguished from nutritional supplements taken\nelectively. Coverage for certain inherited diseases of amino acid and\norganic acid metabolism shall include modified solid food products that\nare low protein, or which contain modified protein which are medically\nnecessary, and such coverage for such modified solid food products for\nany calendar year or for any continuous period of twelve months for any\ninsured individual shall not exceed two thousand five hundred dollars.\n * NB There are 2 sb§ (y)'s\n * (y)(1) Every contract issued by a health service corporation or a\nmedical expense indemnity corporation which is a "managed care product"\nas defined in paragraph four of this subsection that includes coverage\nfor physician services in a physician's office, and every "managed care\nproduct" that provides major medical or similar comprehensive-type\ncoverage, shall include coverage for chiropractic care, as defined in\nsection six thousand five hundred fifty-one of the education law,\nprovided by a doctor of chiropractic licensed pursuant to article one\nhundred thirty-two of the education law, in connection with the\ndetection or correction by manual or mechanical means of structural\nimbalance, distortion or subluxation in the human body for the purpose\nof removing nerve interference, and the effects thereof, where such\ninterference is the result of or related to distortion, misalignment or\nsubluxation of or in the vertebral column. However, chiropractic care\nand services may be subject to reasonable deductible, co-payment and\nco-insurance amounts, reasonable fee or benefit limits, and reasonable\nutilization review, provided that any such amounts, limits and review:\n(a) shall not function to direct treatment in a manner discriminative\nagainst chiropractic care, and (b) individually and collectively shall\nbe no more restrictive than those applicable under the same policy to\ncare or services provided by other health professionals in the\ndiagnosis, treatment and management of the same or similar conditions,\ninjuries, complaints, disorders or ailments, even if differing\nnomenclature is used to describe the condition, injury, complaint,\ndisorder or ailment. Nothing herein contained shall be construed as\nimpeding or preventing either the provision or coverage of chiropractic\ncare and services by duly licensed doctors of chiropractic, within the\nlawful scope of chiropractic practice, in hospital facilities on a staff\nor employee basis.\n (3) Every contract issued by a health service corporation or a medical\nexpense indemnity corporation which includes coverage for physician\nservices in a physician's office, and every contract which provides\nmajor medical or similar comprehensive-type coverage, other than a\n"managed care product" as defined in paragraph four of this subsection,\nshall provide coverage for chiropractic care, as defined in section six\nthousand five hundred fifty-one of the education law, provided by a\ndoctor of chiropractic licensed pursuant to article one hundred\nthirty-two of the education law, in connection with the detection or\ncorrection by manual or mechanical means of structural imbalance,\ndistortion or subluxation in the human body for the purpose of removing\nnerve interference, and the effects thereof, where such interference is\nthe result of or related to distortion, misalignment or subluxation of\nor in the vertebral column. However, chiropractic care and services may\nbe subject to reasonable deductible, co-payment and co-insurance\namounts, reasonable fee or benefit limits, and reasonable utilization\nreview, provided that any such amounts, limits and review: (a) shall\nnot function to direct treatment in a manner discriminative against\nchiropractic care, and (b) individually and collectively shall be no\nmore restrictive than those applicable under the same contract to care\nor services provided by other health professionals in the diagnosis,\ntreatment and management of the same or similar conditions, injuries,\ncomplaints, disorders or ailments even if differing nomenclature is used\nto describe the condition, injury, complaint, disorder or ailment.\nNothing herein contained shall be construed as impeding or preventing\neither the provision or coverage of chiropractic care and services by\nduly licensed doctors of chiropractic, within the lawful scope of\nchiropractic practice, in hospital facilities on a staff or employee\nbasis.\n (4) For purposes of this subsection, a "managed care product" shall\nmean a contract which requires that medical or other health care\nservices covered under the contract, other than emergency care services,\nbe provided by, or pursuant to a referral from, a primary care provider,\nand that services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the corporation's managed care\nprovider network. In addition, a managed care product shall also mean\nthe in-network portion of a contract which requires that medical or\nother health care services covered under the contract, other than\nemergency care services, be provided by, or pursuant to a referral from,\na primary care provider, and that services provided pursuant to such a\nreferral be rendered by a health care provider participating in the\ncorporation's managed care provider network, in order for the insured to\nbe entitled to the maximum reimbursement under the contract.\n (5) The coverage required by this subsection shall not be abridged by\nany regulation promulgated by the superintendent.\n * NB There are 2 sb§ (y)'s\n (z) No contract issued by a medical expense indemnity corporation, a\nhospital service corporation or a health service corporation shall\nexclude coverage of a health care service, as defined in paragraph two\nof subsection (e) of section four thousand nine hundred of this chapter,\nrendered or proposed to be rendered to an insured on the basis that such\nservice is experimental or investigational, is rendered as part of a\nclinical trial as defined in subsection (b-2) of section forty-nine\nhundred of this chapter, or a prescribed pharmaceutical product\nreferenced in subparagraph (B) of paragraph two of subsection (e) of\nsection forty-nine hundred of this chapter provided that coverage of the\npatient costs of such service has been recommended for the insured by an\nexternal appeal agent upon an appeal conducted pursuant to subparagraph\n(B) of paragraph four of subsection (b) of section four thousand nine\nhundred fourteen of this chapter. The determination of the external\nappeal agent shall be binding on the parties. For purposes of this\nparagraph, patient costs shall have the same meaning as such term has\nfor purposes of subparagraph (B) of paragraph four of subsection (b) of\nsection four thousand nine hundred fourteen of this chapter; provided,\nhowever, that coverage for the services required under this subsection\nshall be provided subject to the terms and conditions generally\napplicable to other benefits provided under the policy.\n (z-1) (1) Every policy delivered or issued for delivery in this state\nwhich provides medical coverage that includes coverage for physician\nservices in a physician's office and every policy which provides major\nmedical or similar comprehensive-type coverage shall provide, upon the\nprescription of a health care provider legally authorized to prescribe\nunder title eight of the education law, the following coverage for\ndiagnostic screening for prostatic cancer:\n (A) standard diagnostic testing including, but not limited to, a\ndigital rectal examination and a prostate-specific antigen test at any\nage for men having a prior history of prostate cancer; and\n (B) an annual standard diagnostic examination including, but not\nlimited to, a digital rectal examination and a prostate-specific antigen\ntest for men age fifty and over who are asymptomatic and for men age\nforty and over with a family history of prostate cancer or other\nprostate cancer risk factors.\n (2) Such coverage may be subject to annual deductibles and coinsurance\nas may be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy.\n (aa)(1) Every contract issued by a hospital service company or health\nservice corporation which provides major medical or similar\ncomprehensive-type coverage shall include coverage for prehospital\nemergency medical services for the treatment of an emergency condition\nwhen such services are provided by an ambulance service issued a\ncertificate to operate pursuant to section three thousand five of the\npublic health law.\n (2) Payment by an insurer pursuant to this section shall be payment in\nfull for the services provided. An ambulance service reimbursed pursuant\nto this section shall not charge or seek any reimbursement from, or have\nany recourse against an insured for the services provided pursuant to\nthis subsection, except for the collection of copayments, coinsurance or\ndeductibles for which the insured is responsible for under the terms of\nthe policy.\n (3) An insurer shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the insurer and\nthe provider of such services. In the absence of agreed upon rates, an\ninsurer shall pay for such services at the usual and customary charge,\nwhich shall not be excessive or unreasonable.\n (4) The provisions of this subsection shall have no application to\ntransfers of patients between hospitals or health care facilities by an\nambulance service as described in paragraph one of this subsection.\n (5) As used in this subsection:\n (A) "Prehospital emergency medical services" means the prompt\nevaluation and treatment of an emergency medical condition, and/or\nnon-air-borne transportation of the patient to a hospital; provided\nhowever, where the patient utilizes non-air-borne emergency\ntransportation pursuant to this subsection, reimbursement shall be based\non whether a prudent layperson, possessing an average knowledge of\nmedicine and health, could reasonably expect the absence of such\ntransportation to result in (i) placing the health of the person\nafflicted with such condition in serious jeopardy, or in the case of a\nbehavioral condition placing the health of such person or others in\nserious jeopardy; (ii) serious impairment to such person's bodily\nfunctions; (iii) serious dysfunction of any bodily organ or part of such\nperson; (iv) serious disfigurement of such person; or (v) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nSocial Security Act.\n (B) "Emergency condition" means a medical or behavioral condition that\nmanifests itself by acute symptoms of sufficient severity, including\nsevere pain, such that a prudent layperson, possessing an average\nknowledge of medicine and health, could reasonably expect the absence of\nimmediate medical attention to result in (i) placing the health of the\nperson afflicted with such condition in serious jeopardy, or in the case\nof a behavioral condition, placing the health of such person or others\nin serious jeopardy; (ii) serious impairment to such person's bodily\nfunctions; (iii) serious dysfunction of any bodily organ or part of such\nperson; (iv) serious disfigurement of such person; or (v) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nSocial Security Act.\n (bb) A health service corporation or a medical service expense\nindemnity corporation that provides major medical or similar\ncomprehensive-type coverage shall provide such coverage for bone mineral\ndensity measurements or tests, and if such contract otherwise includes\ncoverage for prescription drugs, drugs and devices approved by the\nfederal food and drug administration or generic equivalents as approved\nsubstitutes. In determining appropriate coverage provided by paragraphs\none, two and three of this subsection, the insurer or health maintenance\norganization shall adopt standards that include the criteria of the\nfederal Medicare program and the criteria of the national institutes of\nhealth for the detection of osteoporosis, provided that such coverage\nshall be further determined as follows:\n (1) For purposes of paragraphs two and three of this subsection, bone\nmineral density measurements or tests, drugs and devices shall include\nthose covered under the criteria of the federal Medicare program as well\nas those in accordance with the criteria of the national institutes of\nhealth, including, as consistent with such criteria, dual-energy x-ray\nabsorptiometry.\n (2) For purposes of paragraphs one and three of this subsection, bone\nmineral density measurements or tests, drugs and devices shall be\ncovered for individuals meeting the criteria for coverage, consistent\nwith the criteria under the federal Medicare program or the criteria of\nthe national institutes of health; provided that, to the extent\nconsistent with such criteria, individuals qualifying for coverage\nshall, at a minimum, include individuals:\n (i) previously diagnosed as having osteoporosis or having a family\nhistory of osteoporosis; or\n (ii) with symptoms or conditions indicative of the presence, or the\nsignificant risk, of osteoporosis; or\n (iii) on a prescribed drug regimen posing a significant risk of\nosteoporosis; or\n (iv) with lifestyle factors to such a degree as posing a significant\nrisk of osteoporosis; or\n (v) with such age, gender and/or other physiological characteristics\nwhich pose a significant risk for osteoporosis.\n (3) Such coverage required pursuant to paragraph one or two of this\nsubsection may be subject to annual deductibles and coinsurance as may\nbe deemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy.\n (4) In addition to paragraph one, two or three of this subsection,\nevery contract that provides hospital, surgical or medical care\ncoverage, except for a grandfathered health plan under paragraph five of\nthis subsection, shall provide coverage for the following items or\nservices for bone mineral density, and such coverage shall not be\nsubject to annual deductibles or coinsurance:\n (A) evidence-based items or services for bone mineral density that\nhave in effect a rating of 'A' or 'B' in the current recommendations of\nthe United States preventive services task force; and\n (B) with respect to women, such additional preventive care and\nscreenings for bone mineral density not described in subparagraph (A) of\nthis paragraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n (5) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n (cc) Every contract which provides coverage for prescription drugs\nshall include coverage for the cost of contraceptive drugs or devices\napproved by the federal food and drug administration or generic\nequivalents approved as substitutes by such food and drug administration\nunder the prescription of a health care provider legally authorized to\nprescribe under title eight of the education law. The coverage required\nby this section shall be included in contracts and certificates only\nthrough the addition of a rider.\n (1) Notwithstanding any other provision of this subsection, a\nreligious employer may request a contract without coverage for federal\nfood and drug administration approved contraceptive methods that are\ncontrary to the religious employer's religious tenets. If so requested,\nsuch contract shall be provided without coverage for contraceptive\nmethods. This paragraph shall not be construed to deny an enrollee\ncoverage of, and timely access to, contraceptive methods.\n (A) For purposes of this subsection, a "religious employer" is an\nentity for which each of the following is true:\n (i) The inculcation of religious values is the purpose of the entity.\n (ii) The entity primarily employs persons who share the religious\ntenets of the entity.\n (iii) The entity serves primarily persons who share the religious\ntenets of the entity.\n (iv) The entity is a nonprofit organization as described in Section\n6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.\n (B) Every religious employer that invokes the exemption provided under\nthis paragraph shall provide written notice to prospective enrollees\nprior to enrollment with the plan, listing the contraceptive health care\nservices the employer refuses to cover for religious reasons.\n (2)(A) Where a group contractholder makes an election not to purchase\ncoverage for contraceptive drugs or devices in accordance with paragraph\none of this subsection, each enrollee covered under the contract issued\nto that group contractholder shall have the right to directly purchase\nthe rider required by this subsection from the insurer or health\nmaintenance organization which issued the group contract at the\nprevailing small group community rate for such rider whether or not the\nemployee is part of a small group.\n (B) Where a group contractholder makes an election not to purchase\ncoverage for contraceptive drugs or devices in accordance with paragraph\none of this subsection, the insurer or health maintenance organization\nthat provides such coverage shall provide written notice to enrollees\nupon enrollment with the insurer or health maintenance organization of\ntheir right to directly purchase a rider for coverage for the cost of\ncontraceptive drugs or devices. The notice shall also advise the\nenrollees of the additional premium for such coverage.\n (3) Nothing in this subsection shall be construed as authorizing a\ncontract which provides coverage for prescription drugs to exclude\ncoverage for prescription drugs prescribed for reasons other than\ncontraceptive purposes.\n (4) Such coverage may be subject to reasonable annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other drugs or devices covered\nunder the policy.\n (dd) No health service corporation or medical service expense\nindemnity corporation which provides medical, major medical or similar\ncomprehensive-type coverage shall exclude coverage for services covered\nunder such policy when provided by a comprehensive care center for\neating disorders pursuant to article twenty-seven-J of the public health\nlaw; provided, however, that reimbursement by such corporation for\nservices provided through such comprehensive care centers shall, to the\nextent possible and practicable, be structured in a manner to facilitate\nthe individualized, comprehensive and integrated plans of care which\nsuch centers' network of practitioners and providers are required to\nprovide.\n (ee) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation which provides coverage for\nhospital or surgical care coverage shall not exclude coverage for\nscreening, diagnosis and treatment of medical conditions otherwise\ncovered by the contract solely because the treatment is provided to\ndiagnose or treat autism spectrum disorder.\n (2) Every contract that provides physician services, medical, major\nmedical or similar comprehensive-type coverage shall provide coverage\nfor the screening, diagnosis and treatment of autism spectrum disorder\nin accordance with this paragraph and shall not exclude coverage for the\nscreening, diagnosis or treatment of medical conditions otherwise\ncovered by the contract because the individual is diagnosed with autism\nspectrum disorder. Such coverage may be subject to annual deductibles,\ncopayments and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the contract. Coverage for applied behavior analysis\nshall be subject to a maximum benefit of six hundred eighty hours of\ntreatment per contract or calendar year per covered individual. This\nparagraph shall not be construed as limiting the benefits that are\notherwise available to an individual under the contract, provided\nhowever that such contract shall not contain any limitations on visits\nthat are solely applied to the treatment of autism spectrum disorder. No\ninsurer shall terminate coverage or refuse to deliver, execute, issue,\namend, adjust, or renew coverage to an individual solely because the\nindividual is diagnosed with autism spectrum disorder or has received\ntreatment for autism spectrum disorder. Coverage shall be subject to\nutilization review and external appeals of health care services pursuant\nto article forty-nine of this chapter as well as, case management, and\nother managed care provisions.\n (3) For purposes of this subsection:\n (A) "autism spectrum disorder" means any pervasive developmental\ndisorder as defined in the most recent edition of the diagnostic and\nstatistical manual of mental disorders, including autistic disorder,\nAsperger's disorder, Rett's disorder, childhood disintegrative disorder,\nor pervasive developmental disorder not otherwise specified (PDD-NOS).\n (B) "applied behavior analysis" means the design, implementation, and\nevaluation of environmental modifications, using behavioral stimuli and\nconsequences, to produce socially significant improvement in human\nbehavior, including the use of direct observation, measurement, and\nfunctional analysis of the relationship between environment and\nbehavior.\n (C) "behavioral health treatment" means counseling and treatment\nprograms, when provided by a licensed provider, and applied behavior\nanalysis, when provided or supervised by a behavior analyst certified\npursuant to the behavior analyst certification board, that are necessary\nto develop, maintain, or restore, to the maximum extent practicable, the\nfunctioning of an individual. Individuals that provide behavioral health\ntreatment under the supervision of a certified behavior analyst pursuant\nto this subsection shall be subject to standards of professionalism,\nsupervision and relevant experience pursuant to regulations promulgated\nby the superintendent in consultation with the commissioners of health\nand education.\n (D) "diagnosis of autism spectrum disorder" means assessments,\nevaluations, or tests to diagnose whether an individual has autism\nspectrum disorder.\n (E) "pharmacy care" means medications prescribed by a licensed health\ncare provider legally authorized to prescribe under title eight of the\neducation law.\n (F) "psychiatric care" means direct or consultative services provided\nby a psychiatrist licensed in the state in which the psychiatrist\npractices.\n (G) "psychological care" means direct or consultative services\nprovided by a psychologist licensed in the state in which the\npsychologist practices.\n (H) "therapeutic care" means services provided by licensed or\ncertified speech therapists, occupational therapists, social workers, or\nphysical therapists.\n (I) "treatment of autism spectrum disorder" shall include the\nfollowing care and assistive communication devices prescribed or ordered\nfor an individual diagnosed with autism spectrum disorder by a licensed\nphysician or a licensed psychologist:\n (i) behavioral health treatment;\n (ii) psychiatric care;\n (iii) psychological care;\n (iv) medical care provided by a licensed health care provider;\n (v) therapeutic care, including therapeutic care which is deemed\nhabilitative or nonrestorative, in the event that the policy provides\ncoverage for therapeutic care; and\n (vi) pharmacy care in the event that the contract provides coverage\nfor prescription drugs.\n (4) Coverage may be denied on the basis that such treatment is being\nprovided to the covered person pursuant to an individualized education\nplan under article eighty-nine of the education law. The provision of\nservices pursuant to an individualized family service plan under section\ntwenty-five hundred forty-five of the public health law, an\nindividualized education plan under article eighty-nine of the education\nlaw, or an individualized service plan pursuant to regulations of the\noffice for persons with developmental disabilities shall not affect\ncoverage under the policy for services provided on a supplemental basis\noutside of an educational setting if such services are prescribed by a\nlicensed physician or licensed psychologist.\n (5) Nothing in this subsection shall be construed to affect any\nobligation to provide services to an individual under an individualized\nfamily service plan under section twenty-five hundred forty-five of the\npublic health law, an individualized education plan under article\neighty-nine of the education law, or an individualized service plan\npursuant to regulations of the office for persons with developmental\ndisabilities.\n (6) Nothing in this subsection shall be construed to affect any\nobligation to provide coverage for otherwise-covered services solely on\nthe basis that the services constitute early intervention program\nservices pursuant to section three thousand two hundred thirty-five-a of\nthis article or an individualized service plan pursuant to regulations\nof the office for persons with developmental disabilities.\n (7) Nothing in this subsection shall be construed to prevent a\ncontract from providing services through a network of participating\nproviders who shall meet certain requirements for participation,\nincluding provider credentialing.\n (ff) (1) No managed care contract issued by a health service\ncorporation, hospital service corporation or medical expense indemnity\ncorporation that provides coverage for hospital, medical or surgical\ncare shall provide that services of a participating hospital will be\ncovered as out-of-network services solely on the basis that the health\ncare provider admitting or rendering services to the insured is not a\nparticipating provider.\n (2) No managed care contract issued by a health service corporation,\nhospital service corporation or medical expense indemnity corporation\nthat provides coverage for hospital, medical or surgical care shall\nprovide that services of a participating health care provider will be\ncovered as out-of-network services solely on the basis that the services\nare rendered in a non-participating hospital.\n (3) For purposes of this subsection, a "health care provider" is a\nhealth care professional licensed, registered or certified pursuant to\ntitle eight of the education law or a health care professional\ncomparably licensed, registered or certified by another state.\n (4) For purposes of this subsection, a "managed care contract" is a\ncontract that requires that services be provided by a provider\nparticipating in the corporation's network in order for the subscriber\nto receive the maximum level of reimbursement under the contract.\n (gg) (1) Every contract issued by a hospital service corporation,\nhealth service corporation or medical expense indemnity corporation that\nincludes coverage for dialysis treatment that requires such services to\nbe provided by an in-network provider and that does not provide coverage\nfor out-of-network dialysis treatment shall not deny coverage of such\nservices because the services are provided by an out-of-network\nprovider, provided that each of the following conditions are met:\n (A) The out-of-network provider is duly licensed to practice and\nauthorized to provide such treatment;\n (B) The out-of-network provider is located outside the service area of\nthe insurer;\n (C) The in-network healthcare provider treating the covered person for\nthe condition issues a written order for dialysis treatment stating that\nin his or her opinion such treatment is necessary;\n (D) The covered person has notified, in writing, the corporation at\nleast thirty days in advance of the proposed date or dates of such\nout-of-network dialysis treatment. The notice shall include the\nauthorization required by subparagraph (C) of this paragraph. In the\nevent the covered person must travel on sudden notice due to family or\nother emergency, shorter notice may be permitted, provided that the\ncorporation has reasonable opportunity to review the travel and\ntreatment plans of the covered person;\n (E) The corporation shall have the right to pre-approve the dialysis\ntreatment and schedule; and\n (F) Such coverage is limited to no greater than ten out-of-network\ntreatments in a calendar year.\n (2) Where coverage for out-of-network dialysis treatment is provided\npursuant to paragraph one of this subsection, no corporation shall be\nobligated to reimburse the out-of-network provider at an amount greater\nthan it would have paid for the same treatment within a network,\nincluding all drugs and ancillary services tied to dialysis treatment,\nand any amount charged by a provider in excess of the amount reimbursed\nby the corporation shall be the responsibility of the covered person\nreceiving the out-of-network services.\n (3) Such coverage of out-of-network dialysis services required by\nparagraph one of this subsection shall otherwise be subject to the\nlimitations, exclusions and terms of the policy, including, but not\nlimited to, utilization review, annual deductibles, copayments, and\ncoinsurance, consistent with those required for other similar benefits\nunder the policy.\n (hh) Notwithstanding title eleven of article five of the social\nservices law or any other law to the contrary, every policy which\nprovides coverage for prescription drugs shall, with regard to eye drop\nmedication requiring a prescription that has been approved by the\ninsurer for coverage, allow for the limited refilling of the\nprescription prior to the last day of the approved dosage period without\nregard to any coverage restrictions on early refill of renewals.\nProvided, however, that any refill dispensed prior to the expiration of\nthe prescribed and approved coverage period pursuant to this subsection,\nshall, to the extent practicable, be limited in quantity so as not to\nexceed the remaining dosage initially approved for coverage. Provided,\nfurther, that such limited refilling shall not limit or restrict\ncoverage with regard to any previously or subsequently approved\nprescription for eye drop medication and shall be subject to the terms\nand conditions of the policy otherwise applicable to this coverage.\nProvided, further, that a pharmacist may contact the prescribing\nphysician or health care provider to verity the prescription.\n (ii) Every contract issued by a corporation subject to the provisions\nof this article which provides medical, major medical or similar\ncomprehensive-type coverage that includes coverage for a physical or\nwell care visit once in every three hundred sixty-five days shall be\ninterpreted to mean that such physical or well care visit can be had\nonce every calendar year, regardless of whether or not a period of three\nhundred sixty-five days has passed since the previous physical or well\ncare visit.\n (jj) No medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation which provides coverage for\nprescription drugs and for which cost-sharing, deductibles or\nco-insurance obligations are determined by category of prescription\ndrugs shall impose cost-sharing, deductibles or co-insurance obligations\nfor any prescription drug that exceeds the dollar amount of\ncost-sharing, deductibles or co-insurance obligations for non-preferred\nbrand drugs or its equivalent (or brand drugs if there is no\nnon-preferred brand drug category).\n (kk) Any contract issued by a medical expense indemnity corporation, a\nhospital service corporation or a health services corporation that\nprovides coverage for prescription drugs shall permit each covered\nperson to fill any covered prescription that may be obtained at a\nnetwork participating mail order or other non-retail pharmacy, at the\ncovered person's option, at a network participating non-mail order\nretail pharmacy provided that the network participating non-mail order\nretail pharmacy agrees in advance, through a contractual network\nagreement, to the same reimbursement amount, as well as the same\napplicable terms and conditions, that the corporation has established\nfor the network participating mail order or other non-retail pharmacy.\nIn such a case, the contract shall not impose a copayment fee or other\ncondition on any covered person who elects to purchase drugs from a\nnetwork participating non-mail order retail pharmacy which is not also\nimposed on covered persons electing to purchase drugs from a network\nparticipating mail order or other non-retail pharmacy; provided,\nhowever, that the provisions of this section shall not supersede the\nterms of a collective bargaining agreement or apply to a contract that\nis the result of a collective bargaining agreement between an employer\nand a recognized or certified employee organization.\n (ll) Every small group contract or association group contract\ndelivered or issued for delivery in this state that provides coverage\nfor hospital, medical or surgical expense insurance and is not a\ngrandfathered health plan shall provide coverage for the essential\nhealth benefit package as required in section 2707(a) of the public\nhealth service act, 42 U.S.C. § 300gg-6(a). For purposes of this\nsubsection:\n (1) "essential health benefits package" shall have the meaning set\nforth in section 1302(a) of the affordable care act, 42 U.S.C. §\n18022(a);\n (2) "grandfathered health plan" means coverage provided by a\ncorporation in which an individual was enrolled on March twenty-third,\ntwo thousand ten for as long as the coverage maintains grandfathered\nstatus in accordance with section 1251(e) of the affordable care act, 42\nU.S.C. § 18011(e); and\n (3) "small group" means a group of fifty or fewer employees or members\nexclusive of spouses and dependents. Beginning January first, two\nthousand sixteen, "small group" means a group of one hundred or fewer\nemployees or members exclusive of spouses and dependents; and\n (4) "association group" means a group defined in subparagraphs (B),\n(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section\nfour thousand two hundred thirty-five of this chapter, provided that:\n (A) the group includes one or more individual members; or\n (B) the group includes one or more member employers or other member\ngroups that are small groups.\n (mm) A corporation shall not be required to offer the contract holder\nany benefits that must be made available pursuant to this section if\nsuch benefits must be covered pursuant to subsection (kk) of this\nsection. For any contract issued within the health benefit exchange\nestablished pursuant to section 1311 of the affordable care act, 42\nU.S.C. § 18031, a corporation shall not be required to offer the\ncontract holder any benefits that must be made available pursuant to\nthis section.\n (nn) A corporation subject to the provisions of this article or an\ninsurance producer subject to this chapter shall not permit the renewal\nof a small group policy which provides hospital, surgical or medical\nexpense coverage that renews on or after January first, two thousand\nfourteen, but before July first, two thousand fourteen, so as to renew\nthe same policy prior to the policy's annual renewal date for the sole\npurpose of evading the requirements of the affordable care act and\nregulations promulgated thereunder with respect to such policy. An\nisolated, inadvertent renewal date change which was not made for the\nsole purpose of evading the requirements of the affordable care act\nshall not be deemed a violation of this subsection.\n * (oo) Every contract issued by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation which provides comprehensive coverage for hospital, medical\nor surgical care shall make available and, if requested by a contract\nholder, provide coverage for services which are otherwise covered under\nthe policy that are provided (1) via telemedicine, as defined in section\ntwo of the public health law, provided that such services meet the\nrequirements of federal law, rules and regulations for Medicare (other\nthan any originating site restriction requirements); or (2) telehealth\nservices, as defined in section two of the public health law, provided\nthat such services are consistent with subdivision three-c of section\nthirty-six hundred fourteen of the public health law. The provider of\nsuch services shall meet the terms and conditions (to the extent not\ninconsistent with this subsection) of his or her contract with the\ninsurer. Such coverage required by this subsection may be subject to\nannual deductibles and coinsurance, and other terms and conditions of\ncoverage, including, but not limited to, utilization management and\nother managed care tools, as are consistent with those established for\nthe same services when not provided via telemedicine or telehealth.\n * NB Effective and Repealed January 1, 2016\n * (pp) Every contract issued by a health service corporation or a\nmedical expense indemnity corporation which provides for reimbursement\nfor surgical first assistant services shall provide coverage for such\nservices when provided by a registered nurse first assistant who is\ncertified in operating room nursing provided that: (1) such services are\nwithin the scope of practice of a non-physician surgical first\nassistant; and (2) the terms and conditions of the member contract\notherwise provide for the coverage of such services. Nothing in this\nsubsection shall be construed to: prevent the medical management or\nutilization review of such services; prevent a policy from requiring\nservices through a network of participating providers who shall meet\ncertain requirements for participation, including provider\ncredentialing; or prohibit an insurer from, in its sole discretion,\nproviding a global or capitated payment or electing to directly\nreimburse a non-physician surgical first assistant for such services.\n * NB Effective June 8, 2016\n