senate Bill S5800

Signed By Governor
2011-2012 Legislative Session

Relates to implementation of the Affordable Health Care Act

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Archive: Last Bill Status - Signed by Governor


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed by Governor

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Actions

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jul 20, 2011 signed chap.219
Jul 08, 2011 delivered to governor
Jun 22, 2011 returned to senate
passed assembly
ordered to third reading rules cal.587
substituted for a8460
Jun 20, 2011 referred to insurance
delivered to assembly
passed senate
ordered to third reading cal.1376
Jun 17, 2011 referred to rules

Votes

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S5800 - Bill Details

See Assembly Version of this Bill:
A8460
Law Section:
Insurance Law
Laws Affected:
Amd Ins L, generally; amd §§4403, 4406-b, 4900, 4910, 4912 & 4914, Pub Health L
Versions Introduced in 2011-2012 Legislative Session:
A8457

S5800 - Bill Texts

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Relates to prescription drug coverage, pre-existing conditions and preventive health care; increases the age of dependent children; provides for choice of health care providers; relates to pediatric care; prohibits lifetime and annual coverage limits; eliminates certain appeal requirements; allows commissioner to devise and implement regulations pertaining thereto.

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BILL NUMBER:S5800

TITLE OF BILL:

An act
to amend the insurance law and the public health law, in relation to
implementation of the federal affordable care act
in health insurance policies and contracts

PURPOSE OF BILL:

The purpose of this bill is to amend the Insurance Law and Public
Health Law to implement changes required by the federal Affordable
Care Act in health insurance policies and contracts.

SUMMARY OF PROVISIONS:

Section 1 of the bill would amend Insurance Law § 3105 to provide that
no misrepresentation shall void a contract of hospital, medical,
surgical or prescription drug expense insurance unless, in addition
to being material, the misrepresentation was intentional.

Sections 2, 24, 31 and 35 of the bill would amend Insurance Law
3216(a)(4), 4235(f)(1) and (2), 4304(d)(1) and (3) and 4305(c)(1) to
require a policy or contract of hospital, medical, surgical or
prescription drug expense insurance that covers children to provide
coverage to a married or unmarried child until attaining age
twenty-six, regardless of the child's financial dependence,
residency, student status or employment and to make other technical
corrections.

Sections 3, 13, and 25 of the bill would amend Insurance Law
3216(i)(9), 3221 (k)(4), and 4303(a)(2) to amend the existing
definition of "emergency condition," add definitions of "emergency
services," and "to stabilize" and conform the existing requirements
for coverage of emergency services with the enhanced protections of
2719A(b) of the Public Health Service Act, 42 U.S.C. § 300gg-19a(b)
with respect to grandfathered and non-grandfathered health plans.

Section 4 of the bill would amend Insurance Law § 3216(i)(11) to make
technical corrections to the mammography coverage requirements for
consistency with Insurance Law §§ 3221 and 4303. Section 4 would also
add the mammography coverage requirements of § 2713 of the Public
Health Service Act, 42 U.S.C. § 300gg-13 and clarify that the
coverage required by the Public Health Service Act shall not be
subject to annual deductibles or coinsurance, nor applicable to
grandfathered health plans.

Sections 5, 17 and 28 of the bill would amend Insurance Law
3216(i)(15), 3221 (1)(14) and 4303(t) to add the cervical cytology
coverage requirements of § 2713 of the Public Health Service Act, 42
U.S.C. § 300gg-13 and to clarify that the coverage required by the
Public Health Service Act shall not be subject to annual deductibles
or coinsurance, nor applicable to grand fathered health plans.


Sections 6, 15 and 26 of the bill would amend Insurance Law
3216(i)(17), 3221 (1)(8) and 4303(j) to add the preventive care and
screening coverage requirements for children and adults of § 2713 of
the Public Health Service Act, 42 U.S.C. § 300gg-13 and to clarify
that the coverage required by the Public Health Service Act shall not
be subject to annual deductibles or coinsurance, nor applicable to
grandfathered health plans.

Sections 7, 18 and 29 of the bill would amend Insurance Law
3216(i)(24)(E), 3221 (1)(15)(E), and 4303(aa)(5) to conform the
existing definitions of "prehospital emergency medical services" and
"emergency condition" with the enhanced protections of § 2719A of the
Public Health Service Act, 42 U.S.C. § 300gg-19a for grand fathered
and non-grandfathered health plans.

Sections 8,40 and 60 of the bill would amend Insurance Law §§ 3217-c
and 4306-b and Public Health Law §§ 4406-b to conform the existing
requirements regarding direct access to primary and preventative
obstetric and gynecologic services with § 2719A of the Public Health
Service Act, 42 USC. § 300gg-19a for grandfathered and
nongrandfathered health plans.

Sections 9, 41 and 59 of the bill would add new Insurance Law
3217-e, 4306-d and amend Public Health Law § 4403(7) to require an
insurer or HMO that provides for the designation of a primary care
provider to permit an insured/enrollee to designate any participating
primary care provider who is available to accept the
insured/enrollee, and in the case of a child, to permit the
insured/enrollee to designate a physician (allopathic or osteopathic)
who specializes in pediatrics if such provider participates in the
network of the insurer or HMO.

Sections 10 and 42 of the bill would add new Insurance Law §§ 3217-f
and 4306-e to prohibit insurers from establishing a lifetime limit on
the dollar amount of essential health benefits in an individual,
group or blanket policy or contract of hospital, medical, surgical or
prescription drug expense insurance; to provide that for policy or
contract years beginning January 1,2014, insurers are prohibited from
establishing an annual limit on the dollar amount of essential health
benefits in an individual, group or blanket policy or contract of
hospital, medical, surgical or prescription drug expense insurance,
other than a grandfathered individual policy or contract; and to
provide that for policy or contract years beginning prior to January
1, 2014, insurers may establish restricted annual limits on the
dollar amount of essential health benefits consistent with § 2711 of
the Public Health Service Act, 42 U.S.C. § 300gg-11 or any
regulations thereunder.

Sections 11, 19, 20 and 21 of the bill would amend Insurance Law
3221(e), 3221(m), 3221(p) and 3221(q) to clarify that the term
"dependent" includes a child as described in Insurance Law § 4235(f).

Section 12 of the bill would amend Insurance Law § 3221 (h) with
respect to conversion policies to prohibit an insurer from imposing a
lifetime limit on benefits that are defined as essential health
benefits under § 1302(b) of the Affordable Care Act, 42 U.S.C.
18022(b).


Sections 14 and 30 of the bill would amend Insurance Law
3221(k)(13) and 4303(bb) to add the bone mineral density coverage
requirements of §2713 of the Public Health Service Act, 42 U.S.C.
300gg-13 and to clarify that the coverage required by the Public
Health Service Act shall not be subject to annual deductibles or
coinsurance, nor applicable to grandfathered health plans.

Sections 16 and 27 of the bill would amend Insurance Law §§ 3221
(1)(11) and 4303(p) to add the mammography coverage requirements of
2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13 and to
clarify that the coverage required by the Public Health Service Act
shall not be subject to annual deductibles or coinsurance, nor
applicable to grandfathered health plans.

Sections 22, 34 and 39 of the bill would amend Insurance Law §§ 3221
(r)(1) and (2), 4304(m)(1) and (2) and 4305(1)(1) and (2) to make
technical corrections to provisions regarding coverage for children
until age 29.

Sections 23 and 43 of the bill would add new Insurance Law §§ 3232(f),
(g), (h), (i) and (j) and 4318(f), (g), (h), (i) and (j) to prohibit
insurers in an individual, group or blanket policy or contract of
hospital, medical, surgical or prescription drug expense insurance,
other than in an individual policy or contract that is a
grandfathered health plan, from imposing a pre-existing condition
exclusion on children under the age of 19, for consistency with
2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3.
Sections 23 and 43 would also provide that beginning January 1, 2014,
pursuant to the requirements of §2704 of the Public Health Service
Act, 42 U.S.C. § 300gg-3 insurers are prohibited from imposing a
pre-existing condition exclusion in any individual, group or blanket
policy of hospital, medical, surgical or prescription drug expense
insurance other than in an individual policy or contract that is a
grandfathered health plan.

Sections 32 and 33 of the bill would amend Insurance Law §§ 4304(e)
and 4304(k)(5) to clarify that the term "dependent" includes a child
as described in Insurance Law § 4304(d).

Sections 36, 37 and 38 of the bill would amend Insurance Law
4305(d), 4305(e) and 4305(k) to clarify that the term "dependent"
includes a child as described in Insurance Law § 4305(c).

Section 44 of the bill would amend Insurance Law § 4321 (c) to provide
that with respect to non-grand fathered standardized HMO direct
payment contracts, no copayment shall apply to preventive services or
bone mineral density coverage required pursuant to § 2713 of the
Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 45 of the bill would add a new Insurance Law § 4322(b)(4)(F)
to require that non-grand fathered standardized HMO and POS direct
payment contracts provide coverage for preventive health services
required by § 2713 of the Public Health Service Act, 42 U.S.C.
300gg-13.

Section 46 of the bill would amend Insurance Law § 4322(b)(26) to
require that non-grandfathered standardized HMO and POS direct


payment contracts provide bone mineral density coverage required by
2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 47 of the bill would amend Insurance Law § 4322(c) and (d) to
provide that no copayment shall apply to preventive services or bone
mineral density coverage required pursuant to § 2713 of the Public
Health Service Act, 42 U.S.C. § 300gg-13.
Section 47 would further provide that an out-of-plan lifetime benefit
maximum shall not apply to any benefit defined as an essential health
benefit in § 1302(b) of the Affordable Care Act, 42 U.S.C. § 18022(b).

Section 48 of the bill would add a new Insurance Law § 4326(d)(15)
to require that non-grandfathered Healthy New York contracts provide
coverage for preventive health services required by § 2713 of the
Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 49 of the bill would amend Insurance Law §4326(e)(6) and (7)
to require an individual Healthy New York contract that is a
grandfathered health plan to maintain the $3,000 calendar year limit
on prescription drug coverage; to provide that the maximum dollar
amount on coverage for prescription drugs in an individual contract
that is not a grand fathered health plan or in any group contract
shall be consistent with §2711 of the Public Health Service Act, 42
U.S.C. § 300gg-11 or any regulations thereunder;
and to provide that a copayment shall not apply to preventive health
services provided in accordance with Insurance Law § 4322(d)(15).

Section 50 of the bill would amend Insurance Law § 4326(k) to prohibit
a Healthy New York contract, other than an individual contract that
is a grand fathered health plan, from imposing a pre-existing
condition exclusion on children under the age of 19 for conformance
with § 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3.
Section 51 would also prohibit a Healthy New York contract, other
than a grand fathered individual contract, from imposing a
pre-existing condition exclusion beginning January 1, 2014, pursuant
to the requirements of § 2704 of the Public Health Service Act, 42
U.S.C. § 300gg-3.

Sections 51 and 61 of the bill would amend Insurance Law § 4900(c)
and Public Health Law § 4900(3) to amend the definition of "emergency
condition" for conformance with § 2719A(b) of the Public Health
Service Act, 42 U.S.C. § 300gg-19a(b).

Sections 52 and 62 of the bill would amend Insurance Law § 4900(g-7)
and Public Health Law § 4900(7-g) to remove the requirement that an
insured or enrollee have a life-threatening or disabling condition or
disease to be eligible for an external appeal of a rare disease.

Sections 53 and 63 of the bill would amend Insurance Law
4910(b)(1)(A) and (B) and Public Health Law § 4910(2)(a)(i) and (ii)
to permit an insured or enrollee to pursue an external appeal when a
health care service does not meet the health care plan's requirements
for medical necessity, appropriateness, health care setting, level of
care, or effectiveness of a covered benefit including when the
insured or enrollee is deemed to have exhausted or is not required to
complete an internal appeal pursuant to § 2719 of the Public Health
Service Act, 42 U.S.C. § 300gg-19.


Sections 54 and 64 of the bill would amend Insurance Law
4910(b)(2)(A), (B) and (C) and Public Health Law § 4910(2)(b)(i),
(ii) and (iii) to permit an insured or enrollee to pursue an external
appeal of an experimental or investigational treatment denial when
the insured or enrollee is deemed to have exhausted or is not
required to complete an internal appeal pursuant to § 2719 of the
Public Health Service Act, 42 U.S.C. § 300gg-19 and to remove the
requirement that an insured or enrollee have a life threatening or
disabling condition or disease to be eligible for an external appeal
of an experimental or investigational treatment denial.

Sections 55 and 65 of the bill would amend Insurance Law § 4910(c) and
Public Health Law § 4910(3) to reduce the $50 fee that a health care
plan may currently charge an insured or enrollee for an external
appeal to $25 and to provide that an insured or enrollee shall not
pay more than $75 within a single plan year.

Sections 56 and 66 of the bill would add new Insurance Law
4912(b)(6) and Public Health Law § 4912(2)(f) to require an
organization to be accredited by a nationally recognized private
accrediting organization in order to be a certified as an external
appeal agent.

Sections 57 and 67 of the bill would amend Insurance Law § 4914(b)(1)
and (3) and Public Health Law § 49l4(2)(a) and (c) to provide that an
insured or enrollee shall have four months to file an external
appeal; to permit an insured or enrollee to obtain an expedited
external appeal for reasons permitted by § 2719 of the Public Health
Service Act, 42 U.S.C § 300gg-19; and to require that an expedited
external appeal be completed in no more than 72 hours.

Sections 58 and 68 of the bill would amend Insurance Law
4914(b)(4)(B)(ii)(a) and Public Health Law § 4914(2)(d)(B)(ii)(1) to
remove the requirement that an insured
or enrollee have a life-threatening or disabling condition or disease
to be eligible for an external appeal of an experimental or
investigational treatment denial.

Section 69 of the bill would provide that if any provision of the act
or the application thereof shall be held to be invalid, such
invalidity shall not affect other provisions of the act which can be
given effect without the invalid provision, and, to that end, the
provisions of the act are severable.

Section 70 of the bill sets forth the effective date.

EXISTING LAW:

Insurance Law § 3105 addresses representations by the insured.
Insurance Law § 3216 sets forth the requirements for individual
accident and health insurance policies issued by commercial insurers.
Insurance Law §§ 3217-c and 4306-b and Public Health Law § 4406-b set
forth requirements for an insured's direct access to primary and
preventive obstetric and gynecologic care. Insurance Law §3221 sets
forth requirements for group and blanket accident and health
insurance policies issued by commercial insurers. Insurance Law
3232 and 4318 set forth requirements for pre-existing condition


exclusions in health insurance policies. Insurance Law § 4235 sets
forth requirements for group accident and health insurance policies
issued by commercial insurers, including permissible groups.
Insurance Law § 4303 sets forth benefit requirements for contracts
issued by Article 43 corporations. Insurance Law § 4304 sets forth
requirements for individual contracts issued by Article 43
corporations. Insurance Law § 4305 sets forth requirements for group
contracts issued by Article 43 corporations.
Insurance Law §§ 4321 and 4322 set forth the requirements for
standardized direct payment contracts issued by health maintenance
organizations. Insurance Law § 4326 sets forth the requirements for
individual and small group contracts issued under the Healthy New
York program. Article 49 of the Insurance Law and the Public Health
Law establishes a right to utilization review and external appeal for
consumers and, in certain cases, health care providers. Public Health
Law § 4403 sets forth standards for issuance of a certificate of
authority for a health maintenance organization.

PRIOR LEGISLATIVE HISTORY:

This is a new bill.

STATEMENT IN SUPPORT:

The Patient Protection and Affordable Care Act, Pub. L. 111-148, was
enacted on March 23, 2010. The Health Care and Education
Reconciliation Act, Pub. L. 111-152, was enacted on March 30,
2010. These Acts, collectively referred to as the "Affordable Care
Act", establish consumer protections and mandated benefit
requirements ("six month reforms") that apply to health insurance
policies issued or renewed on or after September 23, 2010. The
Departments of Treasury, Labor, and Health and Human
Services also issued several interim regulations to clarify and
implement certain provisions of the Affordable Care Act.

The Affordable Care Act and regulations promulgated thereunder include
the following protections: requirements for coverage of preventive
services for children and adults with no cost-sharing; coverage of
children to age 26 regardless of financial dependency, residency,
student status or employment; prohibitions on pre-existing condition
exclusions for children up to age 19; direct access to obstetric and
gynecologic services; choice of primary care physician; coverage of
out-of-network emergency services without pre-authorization; internal
and external appeals; prohibitions on the dollar amount of lifetime
and annual limits with respect to essential health benefits; and
permitting rescissions only for fraud or intentional
misrepresentation of material fact.

The Affordable Care Act does not preempt state laws that meet or
exceed protections offered in the Affordable Care Act. However, state
laws that do not meet or exceed the Affordable Care Act protections
must be amended for compliance with the Affordable Care Act. New York
State Insurance Law and Public Health Law currently include
provisions relating to the areas addressed by the "six month
changes". This bill would ensure that existing protections in New
York State Insurance Law and Public Health Law that meet or exceed
the Affordable Care Act protections are maintained, while remaining


provisions are brought into compliance. To the extent that there is
overlap between the existing state requirements for coverage of
preventive health services and the new Affordable Care Act
requirements, coverage must be provided for those overlapping
preventive health services with no cost sharing.

Certain Affordable Care Act requirements do not apply to policies that
were in effect on March 23, 2010, the date the Affordable Care Act
was enacted ("grandfathered health plans"). This bill would maintain
the exception for "grand fathered health plans" other than with
respect to the requirements for direct access to obstetric and
gynecologic services, choice of primary care physician, coverage of
emergency services and external appeals. The exception for "grand
fathered health plans" was not maintained in the bill with respect to
requirements for direct access to obstetric and gynecologic services
and choice of primary care physician because existing New York
requirements are very similar to the Affordable Care Act requirements
and extending the Affordable Care Act requirements would provide
consistency among coverages, without impacting cost. In addition, the
exception for "grand fathered health plans" was not maintained with
respect to requirements for coverage of emergency services and
external appeals because uniformity is needed in these areas for
consistent claims handling and costs should not be impacted.

The changes contained in this bill are necessary in order for New York
State to implement and enforce the federal standards enacted in the
Affordable Care Act and the regulations promulgated thereunder.

BUDGET IMPLICATIONS:

There are no budget implications from this bill.

EFFECTIVE DATE:

This bill would take effect immediately. However, for policies renewed
on or after that date but before September 23, 2011, the act would
take effect upon the renewal date. Further, sections eight, nine,
ten, fourteen, fifteen, sixteen, seventeen, eighteen, twenty-three,
twenty-six, twenty-seven, twenty-eight, twenty-nine, thirty, forty,
forty-one, forty-two and forty-three of the act would, with respect to
blanket policies of hospital, medical, surgical or prescription drug
expense insurance covering students pursuant to Insurance Law
4237(a)(3)(C), take effect on January 1, 2012 and apply to policies
issued or renewed on or after that date. Further, sections fifty-two,
fifty-three, fifty-four, fifty-five, fifty-six, fifty-seven,
fifty-eight, sixty-two, sixty-three, sixty-four, sixty-five,
sixty-six, sixty-seven and sixty-eight of the act would take effect
on the later of July 1, 2011 or the date the external appeal
requirements of § 2719 of the Public Health Service Act, 42 U.S.C.
300gg-19 are determined to be effective by the Secretary of Health
and Human Services and apply to a final adverse determination issued
on and after that date.

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                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  5800

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                              June 17, 2011
                               ___________

Introduced by Sen. SEWARD -- (at request of the New York State Insurance
  Department)  -- read twice and ordered printed, and when printed to be
  committed to the Committee on Rules

AN ACT to amend the insurance law and the public health law, in relation
  to implementation of the federal affordable care act in health  insur-
  ance policies and contracts

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Subsection (b) of section 3105  of  the  insurance  law  is
amended to read as follows:
  (b)(1)  No  misrepresentation shall avoid any contract of insurance or
defeat recovery thereunder unless such misrepresentation  was  material.
No  misrepresentation  shall  be deemed material unless knowledge by the
insurer of the facts misrepresented would have led to a refusal  by  the
insurer to make such contract.
  (2)  WITH  RESPECT  TO  A  POLICY  OF  HOSPITAL, MEDICAL, SURGICAL, OR
PRESCRIPTION DRUG EXPENSE INSURANCE SUBJECT TO  ARTICLES  THIRTY-TWO  OR
FORTY-THREE  OF  THIS  CHAPTER,  NO  MISREPRESENTATION  SHALL  AVOID ANY
CONTRACT OF INSURANCE OR DEFEAT RECOVERY THEREUNDER UNLESS THE MISREPRE-
SENTATION WAS ALSO INTENTIONAL.
  S 2. Subsection (a) of section 3216 of the insurance law, paragraph  4
as  amended by section 65-d of part A of chapter 58 of the laws of 2007,
and subparagraph (C) of paragraph 4 as added by chapter 240 of the  laws
of 2009, is amended to read as follows:
  (a) In this section the term:
  (1) "Policy  of accident and health insurance" includes any individual
policy or contract covering the kind or kinds of insurance described  in
paragraph  three  of  subsection (a) of section one thousand one hundred
thirteen of this chapter.
  (2) "Indemnity" means benefits promised.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09858-05-1

S. 5800                             2

  (3) "Family" may include [husband, wife] THE POLICYHOLDER'S SPOUSE, or
dependent children, or any other person dependent upon the policyholder.
  (4) "Dependent children" (A) shall include any children under a speci-
fied age which shall not exceed age nineteen except:
  (i) Any unmarried dependent child, regardless of age, who is incapable
of self-sustaining employment by reason of mental illness, developmental
disability,  or mental retardation as defined in the mental hygiene law,
or physical handicap and who became so incapable prior  to  the  age  at
which dependent coverage would otherwise terminate, shall be included in
coverage subject to any pre-existing conditions limitation applicable to
other dependents[.]; OR
  (ii)  Any  unmarried  student at an accredited institution of learning
may be considered a dependent child until attaining age  twenty-three[.]
FOR  A  POLICY  OTHER  THAN HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION
DRUG EXPENSE INSURANCE; OR
  (III) ANY MARRIED OR UNMARRIED CHILD SHALL BE CONSIDERED  A  DEPENDENT
CHILD UNTIL ATTAINING AGE TWENTY-SIX WITHOUT REGARD TO FINANCIAL DEPEND-
ENCE,  RESIDENCY  WITH  THE POLICYHOLDER, STUDENT STATUS, OR EMPLOYMENT,
FOR A POLICY  OF  HOSPITAL,  MEDICAL,  SURGICAL,  OR  PRESCRIPTION  DRUG
EXPENSE INSURANCE.
  (B)  may  include,  at  the option of the insurer, any unmarried child
until attaining age  twenty-five  FOR  A  POLICY  OTHER  THAN  HOSPITAL,
MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE.
  (C)  In  addition  to the requirements of subparagraphs (A) and (B) of
this paragraph, every insurer issuing a policy OF HOSPITAL, MEDICAL,  OR
SURGICAL EXPENSE INSURANCE pursuant to this section that provides cover-
age  for dependent children must make available and, if requested by the
policyholder, extend coverage under the policy  to  an  unmarried  child
through  age  twenty-nine, without regard to financial dependence who is
not insured by or eligible for coverage under  an  employer  [sponsored]
health  benefit  plan  [covering them] as an employee or member, whether
insured or self-insured, and who lives, works or  resides  in  New  York
state  or  the  service area of the insurer. Such coverage shall be made
available at the inception of all new policies [and at the  first  anni-
versary  date  of a policy following the effective date of this subpara-
graph]. Written notice of the availability of  such  coverage  shall  be
delivered to the policyholder thirty days prior to the inception of such
[group]  policy  [and  thirty  days  prior to the first anniversary date
following the effective date of this subparagraph].
  S 3. Paragraph 9 of subsection (i) of section 3216  of  the  insurance
law,  as added by chapter 705 of the laws of 1996, is amended to read as
follows:
  (9)(A) Every policy  [which]  THAT  provides  coverage  for  inpatient
hospital care shall also include coverage for services to treat an emer-
gency condition in hospital facilities[. An]:
  (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION;
  (II)  REGARDLESS  OF  WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH
SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES;
  (III) IF THE EMERGENCY SERVICES ARE PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION
ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE  REQUIREMENTS  OR  LIMITA-
TIONS  THAT  APPLY  TO  EMERGENCY  SERVICES  RECEIVED FROM PARTICIPATING
PROVIDERS; AND
  (IV) IF THE EMERGENCY SERVICES ARE  PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  THE  COST-SHARING  REQUIREMENT  (EXPRESSED  AS A COPAYMENT OR

S. 5800                             3

COINSURANCE) SHALL BE THE SAME REQUIREMENT  THAT  WOULD  APPLY  IF  SUCH
SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER.
  (B)  ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE
ACT, 42 U.S.C.  S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE
REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT  TO  COVERAGE  OF  EMERGENCY
SERVICES SHALL BE APPLICABLE TO EVERY POLICY SUBJECT TO THIS PARAGRAPH.
  (C)  FOR  PURPOSES OF THIS PARAGRAPH, AN "emergency condition" means a
medical or behavioral condition[, the onset of which  is  sudden,]  that
manifests  itself  by  ACUTE  symptoms of sufficient severity, including
severe pain, SUCH that a prudent layperson, possessing an average  know-
ledge  of  medicine  and  health, could reasonably expect the absence of
immediate medical attention to result in [(A)] (I) placing the health of
the person afflicted with such condition in serious jeopardy, or in  the
case  of  a  behavioral  condition  placing the health of such person or
others in serious jeopardy[, or (B)]; (II) serious  impairment  to  such
person's bodily functions; [(C)] (III) serious dysfunction of any bodily
organ  or  part  of  such person; [or (D)] (IV) serious disfigurement of
such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II)  OR  (III)
OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  (D)  FOR  PURPOSES OF THIS PARAGRAPH, "EMERGENCY SERVICES" MEANS, WITH
RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL  SCREENING  EXAMINATION
AS  REQUIRED  UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S
1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPARTMENT OF  A
HOSPITAL,  INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO THE EMER-
GENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION; AND  (II)
WITHIN  THE  CAPABILITIES  OF  THE STAFF AND FACILITIES AVAILABLE AT THE
HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT AS ARE REQUIRED
UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C.   S 1395DD,  TO
STABILIZE THE PATIENT.
  (E) FOR PURPOSES OF THIS PARAGRAPH, "TO STABILIZE" MEANS, WITH RESPECT
TO  AN  EMERGENCY  CONDITION,  TO  PROVIDE SUCH MEDICAL TREATMENT OF THE
CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROB-
ABILITY, THAT NO MATERIAL DETERIORATION OF THE CONDITION  IS  LIKELY  TO
RESULT  FROM OR OCCUR DURING THE TRANSFER OF THE INSURED FROM A FACILITY
OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA).
  S 4. Paragraph 11 of subsection (i) of section 3216 of  the  insurance
law,  as added by chapter 417 of the laws of 1989, is amended to read as
follows:
  (11) (A) Every policy [which] THAT  provides  coverage  for  hospital,
surgical  or  medical  care  shall  provide  the  following coverage for
mammography screening for occult breast cancer:
  (i) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or [whose mother
or sister has] WHO HAVE A FIRST DEGREE RELATIVE WITH a prior history  of
breast cancer;
  (ii)  a single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive; AND
  (iii) [a mammogram every two years, or more frequently upon the recom-
mendation of a physician, for covered persons aged forty through  forty-
nine, inclusive; and
  (iv)]  an  annual mammogram for covered persons aged [fifty] FORTY and
older.
  (B) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (C) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.

S. 5800                             4

  (C)  For  purposes  OF  SUBPARAGRAPHS  (A)  AND (B) of this paragraph,
mammography screening means an X-ray examination  of  the  breast  using
dedicated  equipment,  including X-ray tube, filter, compression device,
screens, films and cassettes, with an average glandular  radiation  dose
less than 0.5 rem per view per breast.
  (D)  IN  ADDITION  TO  SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH,
EVERY POLICY THAT PROVIDES COVERAGE FOR HOSPITAL,  SURGICAL  OR  MEDICAL
CARE,  EXCEPT  FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF
THIS PARAGRAPH, SHALL PROVIDE COVERAGE  FOR  THE  FOLLOWING  MAMMOGRAPHY
SCREENING  SERVICES,  AND  SUCH  COVERAGE SHALL NOT BE SUBJECT TO ANNUAL
DEDUCTIBLES OR COINSURANCE:
  (I) EVIDENCE-BASED ITEMS OR SERVICES  FOR  MAMMOGRAPHY  THAT  HAVE  IN
EFFECT  A  RATING  OF  'A'  OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  FOR  MAMMOGRAPHY  NOT DESCRIBED IN ITEM (I) OF THIS SUBPARA-
GRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED  BY  THE
HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  5.  Paragraph 15 of subsection (i) of section 3216 of the insurance
law, as amended by chapter 43 of the laws of 1993, is amended to read as
follows:
  (15) (A) Every policy [which]  THAT  provides  hospital,  surgical  or
medical  care coverage or provides reimbursement for laboratory tests or
reimbursement for diagnostic X-ray services shall provide  coverage  for
an  annual  cervical  cytology  screening  for  cervical  cancer and its
precursor states for women aged eighteen and older.
  (B) For purposes OF SUBPARAGRAPHS  (A)  AND  (C)  of  this  paragraph,
cervical  cytology screening shall include an annual pelvic examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services provided in connection with examining and  evaluating  the  Pap
smear.
  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed  appropriate  by  the  superintendent  and as are consistent with
those established for other benefits within a given policy.
  (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR  (C)  OF  THIS  PARAGRAPH,
EVERY  POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE,
EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH  (E)  OF  THIS
PARAGRAPH,  SHALL  PROVIDE  COVERAGE FOR THE FOLLOWING CERVICAL CYTOLOGY
SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT  BE  SUBJECT  TO  ANNUAL
DEDUCTIBLES OR COINSURANCE:
  (I)  EVIDENCE-BASED  ITEMS OR SERVICES FOR CERVICAL CYTOLOGY THAT HAVE
IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS  OF  THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II)  WITH  RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE CARE AND
SCREENINGS FOR CERVICAL CYTOLOGY NOT  DESCRIBED  IN  ITEM  (I)  OF  THIS
SUBPARAGRAPH  AND  AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED
BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN"  MEANS
COVERAGE  PROVIDED  BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON
MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE  COVERAGE  MAIN-

S. 5800                             5

TAINS  GRANDFATHERED  STATUS  IN  ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  6.  Paragraph 17 of subsection (i) of section 3216 of the insurance
law, as added by chapter 728 of the laws of 1993, is amended to read  as
follows:
  (17)  (A) Every policy [which] THAT provides medical, major-medical or
similar comprehensive-type  coverage  shall  provide  coverage  for  the
provision of preventive and primary care services.
  (B)  For  the purposes OF SUBPARAGRAPHS (A), (C) AND (D) of this para-
graph, preventive and primary care services means the following services
rendered to a [dependent] COVERED child of an insured from the  date  of
birth through the attainment of nineteen years;
  (i)  an  initial  hospital check-up and well-child visits scheduled in
accordance with the prevailing clinical standards of a national  associ-
ation  of  pediatric physicians designated by the commissioner of health
(except for any standard that would limit  the  specialty  or  forum  of
licensure  of  the  practitioner  providing  the  service other than the
limits under state law). Coverage for such services  rendered  shall  be
provided  only to the extent that such services are provided by or under
the supervision of a physician, or  other  professional  licensed  under
article  one  hundred  thirty-nine  of  the education law whose scope of
practice pursuant to such law includes  the  authority  to  provide  the
specified  services.  Coverage  shall  be  provided  for  such  services
rendered in a hospital, as defined in section twenty-eight  hundred  one
of  the  public  health  law,  or  in  an office of a physician or other
professional licensed under  article  one  hundred  thirty-nine  of  the
education  law whose scope of practice pursuant to such law includes the
authority to provide the specified services;
  (ii) at each visit, services in accordance with the  prevailing  clin-
ical  standards  of  such  designated  association,  including a medical
history, a  complete  physical  examination,  developmental  assessment,
anticipatory  guidance,  appropriate  immunizations and laboratory tests
which tests are ordered at the time of the visit and  performed  in  the
practitioner's  office, as authorized by law, or in a clinical laborato-
ry; and
  (iii) necessary immunizations, as determined by the superintendent  in
consultation  with  the  commissioner  of health, consisting of at least
adequate dosages of  vaccine  against  diphtheria,  pertussis,  tetanus,
polio,  measles, rubella, mumps, haemophilus influenzae type b and hepa-
titis b, which meet the standards approved by the United  States  public
health service for such biological products.
  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH shall not be subject to annual deductibles [and/or] OR coinsu-
rance.
  (D) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH  shall not restrict or eliminate existing coverage provided by
the policy.
  (E) IN ADDITION TO SUBPARAGRAPH (A), (B), (C) OR  (D)  OF  THIS  PARA-
GRAPH,  EVERY  POLICY  THAT  PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE
COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH  (F)
OF  THIS  PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVENTIVE
CARE AND SCREENINGS FOR INSUREDS, AND SUCH COVERAGE SHALL NOT BE SUBJECT
TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I) EVIDENCE-BASED ITEMS OR SERVICES FOR PREVENTIVE CARE  AND  SCREEN-
INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN-
DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE;

S. 5800                             6

  (II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI-
SORY  COMMITTEE  ON  IMMUNIZATION  PRACTICES  OF THE CENTERS FOR DISEASE
CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED;
  (III)  WITH  RESPECT  TO  CHILDREN, INCLUDING INFANTS AND ADOLESCENTS,
EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE-
HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN-
ISTRATION; AND
  (IV) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  NOT  DESCRIBED  IN  ITEM  (I)  OF  THIS  SUBPARAGRAPH AND AS
PROVIDED  FOR  IN  COMPREHENSIVE  GUIDELINES  SUPPORTED  BY  THE  HEALTH
RESOURCES AND SERVICES ADMINISTRATION.
  (F)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  7.  Subparagraph  (E)  of paragraph 24 of subsection (i) of section
3216 of the insurance law, as added by chapter 506 of the laws of  2001,
is amended to read as follows:
  (E) As used in this paragraph:
  (i)  "Prehospital  emergency medical services" means the prompt evalu-
ation and treatment of an emergency medical condition,  and/or  non-air-
borne  transportation  of  the  patient to a hospital, provided however,
where the patient utilizes non-air-borne emergency transportation pursu-
ant to this paragraph, reimbursement [will] SHALL be based on whether  a
prudent  layperson,  possessing  an  average  knowledge  of medicine and
health, could reasonably expect the absence of  such  transportation  to
result in [(1)] (I) placing the health of the person afflicted with such
condition  in serious jeopardy, or in the case of a behavioral condition
placing the health of such person or others in serious  jeopardy;  [(2)]
(II)  serious  impairment to such person's bodily functions; [(3)] (III)
serious dysfunction of any bodily organ or part of such person; [or (4)]
(IV) serious disfigurement of such person; OR (V) A CONDITION  DESCRIBED
IN  CLAUSE  (I),  (II),  OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL
SECURITY ACT.
  (ii) "Emergency condition" means a medical or  behavioral  condition[,
the  onset  of which is sudden,] that manifests itself by ACUTE symptoms
of sufficient severity, including  severe  pain,  SUCH  that  a  prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably  expect  the absence of immediate medical attention to result
in [(1)] (I) placing the health of the person afflicted with such condi-
tion in serious jeopardy, or in the case of a behavioral condition plac-
ing the health of such person or others in serious jeopardy; [(2)]  (II)
serious  impairment to such person's bodily functions; [(3)] (III) seri-
ous dysfunction of any bodily organ or part of  such  person;  [or  (4)]
(IV)  serious disfigurement of such person; OR (V) A CONDITION DESCRIBED
IN CLAUSE (I), (II), OR (III) OF SECTION  1867(E)(1)(A)  OF  THE  SOCIAL
SECURITY ACT.
  S  8.  Section 3217-c of the insurance law, as added by chapter 554 of
the laws of 2002, is amended to read as follows:
  S 3217-c. Primary and preventive obstetric and gynecologic care.   (a)
No  insurer subject to this article shall by contract, written policy or
procedure limit a female insured's direct access to primary and  preven-
tive  obstetric and gynecologic services, INCLUDING ANNUAL EXAMINATIONS,
CARE RESULTING FROM SUCH ANNUAL EXAMINATIONS,  AND  TREATMENT  OF  ACUTE
GYNECOLOGIC  CONDITIONS,  from  a qualified provider of such services of

S. 5800                             7

her choice from within the plan [to less than two examinations  annually
for  such  services]  or  [to]  FOR any care related to a pregnancy[. In
addition, no insurer subject to this article shall by contract,  written
policy  or  procedure  limit  direct  access  to  primary and preventive
obstetric and gynecologic services required as a result of  such  annual
examinations or as a result of an acute gynecologic condition], provided
that:  (1) such qualified provider discusses such services and treatment
plan with the insured's primary care practitioner in accordance with the
requirements of the insurer; AND (2) SUCH QUALIFIED PROVIDER  AGREES  TO
ADHERE  TO THE INSURER'S POLICIES AND PROCEDURES, INCLUDING ANY APPLICA-
BLE PROCEDURES REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR
SERVICES OTHER THAN OBSTETRIC AND GYNECOLOGIC SERVICES RENDERED BY  SUCH
QUALIFIED  PROVIDER, AND AGREES TO PROVIDE SERVICES PURSUANT TO A TREAT-
MENT PLAN (IF ANY) APPROVED BY THE INSURER.
  (b) AN INSURER SHALL TREAT THE PROVISION OF OBSTETRIC AND  GYNECOLOGIC
CARE,  AND  THE  ORDERING OF RELATED OBSTETRIC AND GYNECOLOGIC ITEMS AND
SERVICES, PURSUANT TO THE DIRECT ACCESS DESCRIBED IN SUBSECTION  (A)  OF
THIS  SECTION BY A PARTICIPATING QUALIFIED PROVIDER OF SUCH SERVICES, AS
THE AUTHORIZATION OF THE PRIMARY CARE PROVIDER.
  (C) It shall be the duty of the administrative officer or other person
in charge of each insurer subject to THE PROVISIONS OF this  article  to
advise  each  female  insured,  in  writing,  of  the provisions of this
section.
  S 9. The insurance law is amended by adding a new  section  3217-e  to
read as follows:
  S  3217-E.  CHOICE OF HEALTH CARE PROVIDER. AN INSURER THAT IS SUBJECT
TO THIS ARTICLE AND REQUIRES OR PROVIDES FOR DESIGNATION BY  AN  INSURED
OF  A  PARTICIPATING  PRIMARY  CARE PROVIDER SHALL PERMIT THE INSURED TO
DESIGNATE ANY PARTICIPATING PRIMARY CARE PROVIDER WHO  IS  AVAILABLE  TO
ACCEPT  SUCH  INDIVIDUAL,  AND  IN THE CASE OF A CHILD, SHALL PERMIT THE
INSURED  TO  DESIGNATE  A  PHYSICIAN  (ALLOPATHIC  OR  OSTEOPATHIC)  WHO
SPECIALIZES  IN  PEDIATRICS AS THE CHILD'S PRIMARY CARE PROVIDER IF SUCH
PROVIDER PARTICIPATES IN THE NETWORK OF THE INSURER.
  S 10. The insurance law is amended by adding a new section  3217-f  to
read as follows:
  S  3217-F.  PROHIBITION ON LIFETIME AND ANNUAL LIMITS.  (A) AN INSURER
SHALL NOT ESTABLISH A LIFETIME LIMIT ON THE DOLLAR AMOUNT  OF  ESSENTIAL
HEALTH  BENEFITS  IN AN INDIVIDUAL, GROUP OR BLANKET POLICY OF HOSPITAL,
MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE.
  (B) AN INSURER SHALL NOT ESTABLISH  AN  ANNUAL  LIMIT  ON  THE  DOLLAR
AMOUNT  OF  ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET
POLICY OF HOSPITAL,  MEDICAL,  SURGICAL  OR  PRESCRIPTION  DRUG  EXPENSE
INSURANCE FOR POLICY YEARS BEGINNING ON AND AFTER JANUARY ONE, TWO THOU-
SAND FOURTEEN.
  (C)  FOR  POLICY  YEARS  BEGINNING  PRIOR TO JANUARY ONE, TWO THOUSAND
FOURTEEN, AN INSURER MAY  ESTABLISH  RESTRICTED  ANNUAL  LIMITS  ON  THE
DOLLAR  AMOUNT  OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP, OR
BLANKET POLICY OF  HOSPITAL,  MEDICAL,  SURGICAL  OR  PRESCRIPTION  DRUG
EXPENSE  INSURANCE  CONSISTENT  WITH  SECTION  2711 OF THE PUBLIC HEALTH
SERVICE ACT, 42 U.S.C.  S 300GG-11 OR ANY REGULATIONS THEREUNDER.
  (D) THE REQUIREMENTS OF SUBSECTIONS (B) AND (C) OF THIS SECTION  SHALL
NOT BE APPLICABLE TO AN INDIVIDUAL POLICY THAT IS A GRANDFATHERED HEALTH
PLAN.  FOR  PURPOSES  OF THIS SECTION, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-

S. 5800                             8

TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  (E)  FOR  PURPOSES  OF THIS SECTION, "ESSENTIAL HEALTH BENEFITS" SHALL
HAVE THE MEANING ASCRIBED BY SECTION 1302(B) OF THE AFFORDABLE CARE ACT,
42 U.S.C. S 18022(B).
  S 11. Subsection (e) of section 3221 of the insurance law  is  amended
by adding a new paragraph 12 to read as follows:
  (12)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR  THOUSAND
TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER.
  S  12.  Subsection (h) of section 3221 of the insurance law is amended
by adding a new paragraph 5 to read as follows:
  (5) FOR THE PURPOSE OF DETERMINING THE BENEFITS PAYABLE FOR A  COVERED
PERSON,  AN  INSURER  SHALL  NOT  IMPOSE  A LIFETIME LIMIT ON THE DOLLAR
AMOUNT OF BENEFITS THAT ARE DEFINED AS ESSENTIAL HEALTH BENEFITS  PURSU-
ANT TO SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B).
  S  13.  Paragraph 4 of subsection (k) of section 3221 of the insurance
law, as added by chapter 705 of the laws of 1996, is amended to read  as
follows:
  (4)  (A)  Every  group policy delivered or issued for delivery in this
state [which] THAT provides coverage for inpatient hospital  care  shall
include  coverage  for services to treat an emergency condition provided
in hospital facilities, except that this provision shall not apply to  a
policy  which  [cover] COVERS persons employed in more than one state or
the benefit structure of which was the subject of collective  bargaining
affecting  persons  who  are  employed in more than one state UNLESS THE
POLICY OTHERWISE PROVIDES COVERAGE FOR SERVICES TO  TREAT  AN  EMERGENCY
CONDITION PROVIDED IN HOSPITAL FACILITIES:
  (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION;
  (II)  REGARDLESS  OF  WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH
SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES;
  (III) IF THE EMERGENCY SERVICES ARE PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION
ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE  REQUIREMENTS  OR  LIMITA-
TIONS  THAT  APPLY  TO  EMERGENCY  SERVICES  RECEIVED FROM PARTICIPATING
PROVIDERS; AND
  (IV) IF THE EMERGENCY SERVICES ARE  PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  THE  COST-SHARING  REQUIREMENT  (EXPRESSED  AS A COPAYMENT OR
COINSURANCE) SHALL BE THE SAME REQUIREMENT  THAT  WOULD  APPLY  IF  SUCH
SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER.
  (B)  ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE
ACT, 42 U.S.C.  S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE
REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT  TO  COVERAGE  OF  EMERGENCY
SERVICES SHALL BE APPLICABLE TO EVERY POLICY SUBJECT TO THIS PARAGRAPH.
  (C)  In  this  paragraph,  an "emergency condition" means a medical or
behavioral condition[, the onset of which  is  sudden,]  that  manifests
itself  by ACUTE symptoms of sufficient severity, including severe pain,
SUCH that a prudent layperson, possessing an average knowledge of  medi-
cine  and  health,  could  reasonably  expect  the  absence of immediate
medical attention to result in (i) placing  the  health  of  the  person
afflicted  with  such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of  such  person  or  others  in
serious  jeopardy[, or]; (ii) serious impairment to such person's bodily
functions; (iii) serious dysfunction of any bodily organ or part of such
person; [or] (iv) serious disfigurement of such person; OR (V) A  CONDI-

S. 5800                             9

TION  DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF
THE SOCIAL SECURITY ACT.
  (D)  IN THIS PARAGRAPH, "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN
EMERGENCY CONDITION:  (I) A MEDICAL SCREENING  EXAMINATION  AS  REQUIRED
UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH
IS  WITHIN  THE  CAPABILITY  OF  THE EMERGENCY DEPARTMENT OF A HOSPITAL,
INCLUDING  ANCILLARY  SERVICES  ROUTINELY  AVAILABLE  TO  THE  EMERGENCY
DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION: AND (II) WITHIN
THE  CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL,
SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT  AS  ARE  REQUIRED  UNDER
SECTION  1867  OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABI-
LIZE THE PATIENT.
  (E) IN THIS PARAGRAPH, "TO STABILIZE" MEANS, WITH RESPECT TO AN  EMER-
GENCY  CONDITION,  TO PROVIDE SUCH MEDICAL TREATMENT OF THE CONDITION AS
MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROBABILITY,  THAT
NO  MATERIAL  DETERIORATION OF THE CONDITION IS LIKELY TO RESULT FROM OR
OCCUR DURING THE TRANSFER OF THE INSURED FROM A FACILITY OR TO DELIVER A
NEWBORN CHILD (INCLUDING THE PLACENTA).
  S 14. Paragraph 13 of subsection (k) of section 3221 of the  insurance
law,  as added by chapter 554 of the laws of 2002, is amended to read as
follows:
  (13) Every group or blanket policy delivered or issued for delivery in
this state [which] THAT provides major  medical  or  similar  comprehen-
sive-type  coverage shall provide such coverage for bone mineral density
measurements or tests, and if such contract otherwise includes  coverage
for  prescription  drugs, drugs and devices approved by the federal food
and drug administration or generic equivalents as approved  substitutes.
In  determining  appropriate coverage provided by SUBPARAGRAPHS (A), (B)
AND (C) OF this paragraph, the insurer or health  maintenance  organiza-
tion  shall  adopt  standards  [which]  THAT include the criteria of the
federal [medicare] MEDICARE program and the  criteria  of  the  national
institutes  of  health  for the detection of osteoporosis, provided that
such coverage shall be further determined as follows:
  (A) for purposes OF SUBPARAGRAPHS (B) AND (C) of this paragraph,  bone
mineral  density  measurements or tests, drugs and devices shall include
those covered under the federal Medicare program as  well  as  those  in
accordance  with  the  criteria  of  the  national institutes of health,
including, as consistent with such criteria, dual-energy  x-ray  absorp-
tiometry.
  (B)  for purposes OF SUBPARAGRAPHS (A) AND (C) of this paragraph, bone
mineral density measurements  or  tests,  drugs  and  devices  shall  be
covered  for individuals meeting the criteria under the federal Medicare
program or the criteria of the national institutes of  health;  provided
that,  to the extent consistent with such criteria, individuals qualify-
ing for coverage shall at a minimum, include individuals:
  (i) previously diagnosed as having osteoporosis  or  having  a  family
history of osteoporosis; or
  (ii)  with  symptoms  or conditions indicative of the presence, or the
significant risk, of osteoporosis; or
  (iii) on a prescribed drug regimen posing a significant risk of osteo-
porosis; or
  (iv) with lifestyle factors to such a degree as posing  a  significant
risk of osteoporosis; or
  (v)  with  such age, gender and/or other physiological characteristics
which pose a significant risk for osteoporosis.

S. 5800                            10

  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.
  (D)  IN  ADDITION  TO  SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH,
EVERY GROUP OR  BLANKET  POLICY  THAT  PROVIDES  HOSPITAL,  SURGICAL  OR
MEDICAL  CARE  COVERAGE,  EXCEPT  FOR  A GRANDFATHERED HEALTH PLAN UNDER
SUBPARAGRAPH (E) OF THIS  PARAGRAPH,  SHALL  PROVIDE  COVERAGE  FOR  THE
FOLLOWING  ITEMS  OR SERVICES FOR BONE MINERAL DENSITY AND SUCH COVERAGE
SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I) EVIDENCE-BASED ITEMS OR SERVICES FOR  BONE  MINERAL  DENSITY  THAT
HAVE  IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF
THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  FOR  BONE  MINERAL DENSITY NOT DESCRIBED IN ITEM (I) OF THIS
SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE  GUIDELINES  SUPPORTED
BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  15.  Paragraph 8 of subsection (l) of section 3221 of the insurance
law, as amended by chapter 728 of the laws of 1993, is amended  to  read
as follows:
  (8)  (A)  Every  insurer  issuing  a group policy for delivery in this
state [which] THAT provides medical, major-medical or similar comprehen-
sive-type coverage [must] SHALL provide coverage for  the  provision  of
preventive and primary care services.
  (B)  In  SUBPARAGRAPHS  (A), (C) AND (D) OF this paragraph, preventive
and primary care services means the following  services  rendered  to  a
[dependent]  COVERED  child of an insured from the date of birth through
the attainment of nineteen years of age:
  (i) an initial hospital check-up and well-child  visits  scheduled  in
accordance  with the prevailing clinical standards of a national associ-
ation of pediatric physicians designated by the commissioner  of  health
(except  for  any  standard  that  would limit the specialty or forum of
licensure of the practitioner  providing  the  service  other  than  the
limits  under  state  law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or  under
the  supervision  of  a  physician, or other professional licensed under
article one hundred thirty-nine of the  education  law  whose  scope  of
practice  pursuant  to  such  law  includes the authority to provide the
specified  services.  Coverage  shall  be  provided  for  such  services
rendered  in  a hospital, as defined in section twenty-eight hundred one
of the public health law, or in  an  office  of  a  physician  or  other
professional  licensed  under  article  one  hundred  thirty-nine of the
education law whose scope of practice pursuant to such law includes  the
authority to provide the specified services;
  (ii)  at  each visit, services in accordance with the prevailing clin-
ical standards of  such  designated  association,  including  a  medical
history,  a  complete  physical  examination,  developmental assessment,
anticipatory guidance, appropriate immunizations  and  laboratory  tests
which  tests  are  ordered at the time of the visit and performed in the
practitioner's office, as authorized by law, or in a clinical  laborato-
ry; and

S. 5800                            11

  (iii)  necessary immunizations, as determined by the superintendent in
consultation with the commissioner of health,  consisting  of  at  least
adequate  dosages  of  vaccine  against  diphtheria, pertussis, tetanus,
polio, measles, rubella, mumps, haemophilus influenzae type b and  hepa-
titis  b,  which meet the standards approved by the United States public
health service for such biological products.
  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH shall not be subject to annual deductibles [and/or] OR coinsu-
rance.
  (D) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH shall not restrict or eliminate existing coverage provided  by
the policy.
  (E)  IN  ADDITION  TO  SUBPARAGRAPH (A), (B), (C) OR (D) OF THIS PARA-
GRAPH, EVERY GROUP POLICY THAT PROVIDES HOSPITAL,  SURGICAL  OR  MEDICAL
CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH
(G)  OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVEN-
TIVE CARE AND SCREENINGS FOR INSUREDS, AND SUCH COVERAGE  SHALL  NOT  BE
SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I)  EVIDENCE-BASED  ITEMS OR SERVICES FOR PREVENTIVE CARE AND SCREEN-
INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN-
DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE;
  (II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI-
SORY COMMITTEE ON IMMUNIZATION PRACTICES  OF  THE  CENTERS  FOR  DISEASE
CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED;
  (III)  WITH  RESPECT  TO  CHILDREN, INCLUDING INFANTS AND ADOLESCENTS,
EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE-
HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN-
ISTRATION; AND
  (IV) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  NOT  DESCRIBED  IN  ITEM  (I)  OF  THIS  SUBPARAGRAPH AND AS
PROVIDED  FOR  IN  COMPREHENSIVE  GUIDELINES  SUPPORTED  BY  THE  HEALTH
RESOURCES AND SERVICES ADMINISTRATION.
  (F)  THE  REQUIREMENTS OF THIS PARAGRAPH SHALL ALSO BE APPLICABLE TO A
BLANKET POLICY OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE COVER-
ING  STUDENTS  PURSUANT  TO  SUBPARAGRAPH  (C)  OF  PARAGRAPH  THREE  OF
SUBSECTION (A) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-SEVEN OF THIS
CHAPTER.
  (G)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  16. Paragraph 11 of subsection (l) of section 3221 of the insurance
law, as amended by chapter 554 of the laws of 2002, is amended  to  read
as follows:
  (11) (A) Every insurer delivering a group or blanket policy or issuing
a  group  or  blanket  policy  for  delivery  in this state [which] THAT
provides coverage for hospital, surgical or medical care  shall  provide
the  following  coverage  for  mammography  screening  for occult breast
cancer:
  (i) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or  who  have  a
first degree relative with a prior history of breast cancer;
  (ii)  a single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive; and
  (iii) an annual mammogram for covered persons aged forty and older.

S. 5800                            12

  (B) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (C) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.
  (C)  For  purposes  OF  SUBPARAGRAPHS  (A)  AND (B) of this paragraph,
mammography screening means an X-ray examination  of  the  breast  using
dedicated  equipment,  including X-ray tube, filter, compression device,
screens, films and cassettes, with an average glandular  radiation  dose
less than 0.5 rem per view per breast.
  (D)  IN  ADDITION  TO  SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH,
EVERY GROUP OR BLANKET  POLICY  THAT  PROVIDES  COVERAGE  FOR  HOSPITAL,
SURGICAL  OR  MEDICAL CARE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER
SUBPARAGRAPH (E) OF THIS  PARAGRAPH,  SHALL  PROVIDE  COVERAGE  FOR  THE
FOLLOWING MAMMOGRAPHY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE
SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I)  EVIDENCE-BASED  ITEMS  OR  SERVICES  FOR MAMMOGRAPHY THAT HAVE IN
EFFECT A RATING OF 'A' OR 'B' IN  THE  CURRENT  RECOMMENDATIONS  OF  THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II)  WITH  RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE CARE AND
SCREENINGS FOR MAMMOGRAPHY NOT DESCRIBED IN ITEM (I)  OF  THIS  SUBPARA-
GRAPH  AND  AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE
HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN"  MEANS
COVERAGE  PROVIDED  BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON
MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE  COVERAGE  MAIN-
TAINS  GRANDFATHERED  STATUS  IN  ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 17. Paragraph 14 of subsection (l) of section 3221 of the  insurance
law,  as  amended by chapter 554 of the laws of 2002, is amended to read
as follows:
  (14) (A) Every group or blanket policy delivered or issued for  deliv-
ery  in  this  state [which] THAT provides hospital, surgical or medical
coverage shall provide coverage for an annual cervical cytology  screen-
ing for cervical cancer and its precursor states for women aged eighteen
and older.
  (B)  For  purposes  OF  SUBPARAGRAPHS  (A)  AND (C) of this paragraph,
cervical cytology screening shall include an annual pelvic  examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services  provided  in  connection with examining and evaluating the Pap
smear.
  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent  and  as  are  consistent  with
those established for other benefits within a given policy.
  (D)  IN  ADDITION  TO  SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH,
EVERY GROUP OR  BLANKET  POLICY  THAT  PROVIDES  HOSPITAL,  SURGICAL  OR
MEDICAL  COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARA-
GRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE  FOR  THE  FOLLOWING
CERVICAL  CYTOLOGY  SCREENING  SERVICES,  AND SUCH COVERAGE SHALL NOT BE
SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I) EVIDENCE-BASED ITEMS OR SERVICES FOR CERVICAL CYTOLOGY  THAT  HAVE
IN  EFFECT  A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  FOR  CERVICAL  CYTOLOGY  NOT  DESCRIBED  IN ITEM (I) OF THIS

S. 5800                            13

SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE  GUIDELINES  SUPPORTED
BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS  ENROLLED  ON
MARCH  TWENTY-THIRD,  TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH  SECTION  1251(E)  OF  THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  18.  Subparagraph  (E) of paragraph 15 of subsection (l) of section
3221 of the insurance law, as added by chapter 506 of the laws of  2001,
is amended to read as follows:
  (E) As used in this paragraph:
  (i)  "Prehospital  emergency medical services" means the prompt evalu-
ation and treatment of an emergency medical condition,  and/or  non-air-
borne  transportation  of  the  patient to a hospital, provided however,
where the patient utilizes non-air-borne emergency transportation pursu-
ant to this paragraph, reimbursement [will] SHALL be based on whether  a
prudent  layperson,  possessing  an  average  knowledge  of medicine and
health, could reasonably expect the absence of  such  transportation  to
result  in [(1)] (I) placing the health of the person affected with such
condition in serious jeopardy, or in the case of a behavioral  condition
placing  the  health of such person or others in serious jeopardy; [(2)]
(II) serious impairment to such person's bodily functions;  [(3)]  (III)
serious dysfunction of any bodily organ or part of such person; [or (4)]
(IV)  serious disfigurement of such person; OR (V) A CONDITION DESCRIBED
IN CLAUSE (I), (II) OR (III) OF  SECTION  1867(E)(1)(A)  OF  THE  SOCIAL
SECURITY ACT.
  (ii)  "Emergency  condition" means a medical or behavioral condition[,
the onset of which is sudden,] that manifests itself by  ACUTE  symptoms
of  sufficient  severity,  including  severe  pain,  SUCH that a prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention  to  result
in [(1)] (I) placing the health of the person afflicted with such condi-
tion in serious jeopardy, or in the case of a behavioral condition plac-
ing  the health of such person or others in serious jeopardy; [(2)] (II)
serious impairment to such person's bodily functions; ([3)] (III)  seri-
ous  dysfunction  of  any  bodily organ or part of such person; [or (4)]
(IV) serious disfigurement of such person; OR (V) A CONDITION  DESCRIBED
IN  CLAUSE  (I),  (II)  OR  (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL
SECURITY ACT.
  S 19. Subsection (m) of section 3221 of the insurance law  is  amended
by adding a new paragraph 8 to read as follows:
  (8)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR  THOUSAND
TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER.
  S  20.  Subsection (p) of section 3221 of the insurance law is amended
by adding a new paragraph 6 to read as follows:
  (6) FOR PURPOSES  OF  THIS  SUBSECTION,  THE  TERM  "DEPENDENT"  SHALL
INCLUDE  A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR THOUSAND
TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER.
  S 21. Subsection (q) of section 3221 of the insurance law  is  amended
by adding a new paragraph 7 to read as follows:
  (7)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR  THOUSAND
TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER.

S. 5800                            14

  S  22.  Paragraphs  1  and  2 of subsection (r) of section 3221 of the
insurance law, as added by chapter 240 of the laws of 2009, are  amended
to read as follows:
  (1)  As  used in this subsection, ["dependent child"] "CHILD" means an
unmarried child through age twenty-nine of an employee or member insured
under a group policy OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE,
regardless of financial dependence, who is not insured  by  or  eligible
for  coverage  under  any  [employee] EMPLOYER health benefit plan as an
employee or member, whether insured  or  self-insured,  and  who  lives,
works  or  resides  in New York state or the service area of the insurer
and who is not covered under title XVIII of  the  United  States  Social
Security Act (Medicare).
  (2) In addition to the conversion privilege afforded by subsection (e)
of  this  section  and the continuation privilege afforded by subsection
(m) of this section, every group policy delivered or issued for delivery
in this state that provides hospital,  [surgical  or  medical  coverage]
MEDICAL  OR  SURGICAL EXPENSE INSURANCE COVERAGE for other than specific
diseases or accidents only, and which provides [dependent] coverage OF A
CHILD that terminates at a specified age, shall, upon application of the
employee, member or [dependent] child, as set  forth  in  [subparagraphs
(B)  or (C)] SUBPARAGRAPH (B) of this paragraph, provide coverage to the
[dependent] child after that specified age and through  age  twenty-nine
without evidence of insurability, subject to all of the terms and condi-
tions of the group policy and the following:
  (A)  An  employer shall not be required to pay all or part of the cost
of  coverage  for  a  [dependent]  child  provided  pursuant   to   this
subsection;
  (B)  An  employee,  member  or  [dependent]  child who wishes to elect
continuation of coverage pursuant to this subsection shall  request  the
continuation in writing:
  (i)  within  sixty  days  following  the date coverage would otherwise
terminate due to reaching the specified age set forth in the group poli-
cy;
  (ii) within sixty days after meeting the requirements for  [dependent]
child status set forth in paragraph one of this subsection when coverage
for the [dependent] child previously terminated; or
  (iii) during an annual thirty-day open enrollment period, as described
in the policy;
  (C) [For twelve months after the effective date of this subsection, an
employee, member or dependent child may elect prospective coverage under
this  subsection  for  a dependent child whose coverage terminated under
the terms of the group policy prior to the  initial  effective  date  of
this subsection;
  (D)] An employee, member or [dependent] child electing continuation as
described  in  this  subsection  shall  pay to the group policyholder or
employer, but not more frequently than on a monthly  basis  in  advance,
the  amount  of  the  required  premium  payment on the due date of each
payment. The written election of continuation, together with  the  first
premium payment required to establish premium payment on a monthly basis
in  advance, shall be given to the group policyholder or employer within
the time periods set forth in [subparagraphs (B) and  (C)]  SUBPARAGRAPH
(B) of this paragraph. Any premium received within the thirty-day period
after the due date shall be considered timely;
  [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
days of the date the [dependent] child would otherwise lose coverage due
to reaching a specified age, the  effective  date  of  the  continuation

S. 5800                            15

coverage shall be the date coverage would have otherwise terminated. For
any  [dependent] child electing to resume coverage during an annual open
enrollment period [or during the twelve-month  initial  open  enrollment
period  described  in subparagraph (C) of this paragraph], the effective
date of the continuation coverage shall be  prospective  no  later  than
thirty days after the election and payment of first premium;
  [(F)] (E) Coverage for a [dependent] child pursuant to this subsection
shall  consist of coverage that is identical to the coverage provided to
the employee or member parent. If coverage is modified under the  policy
for  any  group  of  similarly  situated  employees or members, then the
coverage shall also be modified in the same manner for  any  [dependent]
child;
  [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
following:
  (i) the date the [dependent] child no longer meets the requirements of
paragraph one of this subsection;
  (ii) the end of the period for which premium payments  were  made,  if
there  is a failure to make payment of a required premium payment within
the period of grace described in subparagraph [(D)] (C)  of  this  para-
graph; or
  (iii)  the  date  on  which  the  group  policy  is terminated and not
replaced by coverage under another group policy; and
  [(H)] (G) The  insurer  shall  provide  written  notification  of  the
continuation  privilege described in this subsection and the time period
in which to request continuation to the employee or member:
  (i) in each certificate of coverage; AND
  (ii) at least sixty days prior to termination at the specified age  as
provided in the policy[; and
  (iii)  within  thirty  days  of the effective date of this subsection,
with respect to information concerning a dependent child's  opportunity,
for twelve months after the effective date of this subsection, to make a
written  election to obtain coverage under a policy pursuant to subpara-
graph (C) of this paragraph].
  S 23. Section 3232 of the insurance law is amended by adding four  new
subsections (f), (g), (h) and (i) to read as follows:
  (F)  WITH  RESPECT TO AN INDIVIDUAL UNDER AGE NINETEEN, AN INSURER MAY
NOT IMPOSE ANY PRE-EXISTING CONDITION  EXCLUSION  IN  AN  INDIVIDUAL  OR
GROUP POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE
INSURANCE  PURSUANT  TO  THE  REQUIREMENTS OF SECTION 2704 OF THE PUBLIC
HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, AS MADE  EFFECTIVE  BY  SECTION
1255(2)  OF  THE AFFORDABLE CARE ACT, EXCEPT FOR AN INDIVIDUAL UNDER AGE
NINETEEN COVERED UNDER AN INDIVIDUAL POLICY OF HOSPITAL, MEDICAL, SURGI-
CAL OR PRESCRIPTION DRUG  EXPENSE  INSURANCE  THAT  IS  A  GRANDFATHERED
HEALTH PLAN.
  (G)  BEGINNING  JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN,  PURSUANT TO
SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S  300GG-3,  AN
INSURER  MAY NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDI-
VIDUAL OR GROUP POLICY OF HOSPITAL, MEDICAL,  SURGICAL  OR  PRESCRIPTION
DRUG EXPENSE INSURANCE EXCEPT IN AN INDIVIDUAL POLICY THAT IS A GRANDFA-
THERED HEALTH PLAN.
  (H)  THE REQUIREMENTS OF SUBSECTIONS (F) AND (G) OF THIS SECTION SHALL
ALSO BE APPLICABLE TO A BLANKET POLICY OF HOSPITAL, MEDICAL, SURGICAL OR
PRESCRIPTION DRUG EXPENSE INSURANCE.
  (I) FOR PURPOSES OF SUBSECTIONS (F) AND (G) OF THIS SECTION, "GRANDFA-
THERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER  IN  WHICH  AN
INDIVIDUAL  WAS  ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS

S. 5800                            16

LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN  ACCORDANCE  WITH
SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  24.  Paragraphs  1  and  2 of subsection (f) of section 4235 of the
insurance law, paragraph 1 as amended by chapter  240  of  the  laws  of
2009, and paragraph 2 as amended by chapter 312 of the laws of 2002, are
amended to read as follows:
  (1)  (A)  Any policy of group accident, group health or group accident
and health insurance may include  provisions  for  the  payment  by  the
insurer  of  benefits  for  expenses  incurred  on  account of hospital,
medical or  surgical  care  or  physical  and  occupational  therapy  by
licensed  physical  and occupational therapists upon the prescription or
referral of a physician for the employee or other member of the  insured
group,  [his] THE EMPLOYEE'S OR MEMBER'S spouse, [his] THE EMPLOYEE'S OR
MEMBER'S child or children, or  other  persons  chiefly  dependent  upon
[him] THE EMPLOYEE OR MEMBER for support and maintenance; provided that:
  (I)  A  POLICY  OF  HOSPITAL,  MEDICAL, SURGICAL, OR PRESCRIPTION DRUG
EXPENSE INSURANCE THAT PROVIDES COVERAGE FOR CHILDREN SHALL PROVIDE SUCH
COVERAGE TO A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF  AGE  TWEN-
TY-SIX,  WITHOUT  REGARD  TO  FINANCIAL  DEPENDENCE,  RESIDENCY WITH THE
EMPLOYEE OR MEMBER, STUDENT STATUS, OR EMPLOYMENT, EXCEPT A POLICY  THAT
IS  A  GRANDFATHERED  HEALTH  PLAN  MAY, FOR PLAN YEARS BEGINNING BEFORE
JANUARY FIRST, TWO THOUSAND FOURTEEN, EXCLUDE COVERAGE OF AN ADULT CHILD
UNDER AGE TWENTY-SIX WHO IS ELIGIBLE TO ENROLL IN AN  EMPLOYER-SPONSORED
HEALTH  PLAN OTHER THAN A GROUP HEALTH PLAN OF A PARENT. FOR PURPOSES OF
THIS ITEM, "GRANDFATHERED HEALTH PLAN" MEANS  COVERAGE  PROVIDED  BY  AN
INSURER  IN  WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO
THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED  STATUS
IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
S 18011(E); AND
  (II)  a  policy under which coverage [of a dependent of an employee or
other member of the insured group] terminates at a specified  age  shall
not  so terminate with respect to an unmarried child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability, mental retardation, as defined in the mental hygiene law, or
physical handicap and who became so incapable prior to attainment of the
age  at  which [dependent] coverage would otherwise terminate and who is
chiefly dependent upon such employee or member for support  and  mainte-
nance,  while  the  insurance of the employee or member remains in force
and the [dependent] CHILD remains in  such  condition,  if  the  insured
employee  or  member  has  within  thirty-one days of such [dependent's]
CHILD'S attainment of  the  termination  age  submitted  proof  of  such
[dependent's] CHILD'S incapacity as described herein.
  (B)  In addition to the requirements of subparagraph (A) of this para-
graph, every insurer issuing a group  policy  OF  HOSPITAL,  MEDICAL  OR
SURGICAL EXPENSE INSURANCE pursuant to this section that provides cover-
age  for  [dependent]  children, must make available and if requested by
the policyholder, extend coverage under the policy to an unmarried child
through age twenty-nine, without regard to financial dependence  who  is
not  insured by or eligible for coverage under any employer health bene-
fit plan as an employee or member, whether insured or self-insured,  and
who lives, works or resides in New York state or the service area of the
insurer.  Such  coverage shall be made available at the inception of all
new policies and with respect to all other policies at  any  anniversary
date.  Written  notice  of  the  availability  of such coverage shall be
delivered to the policyholder prior to the inception of such group poli-
cy and annually thereafter.

S. 5800                            17

  (2) Notwithstanding any rule, regulation or law to the  contrary,  any
family coverage available under this article shall provide that coverage
of  newborn infants, including newly born infants adopted by the insured
or subscriber if such insured or subscriber takes  physical  custody  of
the  infant  upon  such  infant's  release from the hospital and files a
petition pursuant to section  one  hundred  fifteen-c  of  the  domestic
relations  law within thirty days of birth; and provided further that no
notice of revocation to the adoption has been filed pursuant to  section
one  hundred  fifteen-b of the domestic relations law and consent to the
adoption has not been revoked, shall be effective  from  the  moment  of
birth  for injury or sickness including the necessary care and treatment
of  medically  diagnosed  congenital  defects  and  birth  abnormalities
including premature birth, except that in cases of adoption, coverage of
the initial hospital stay shall not be required where a birth parent has
insurance coverage available for the infant's care. In the case of indi-
vidual  coverage  the  insurer  must  also permit the person to whom the
certificate is issued to elect such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or contribution is required to make coverage  effective  for  a  newborn
infant, the coverage may provide that such notice and/or payment be made
within  no  less  than  thirty days of the day of birth to make coverage
effective from the moment of birth. This election shall not be  required
in  the  case  of  student  insurance or where the group's plan does not
provide coverage for [dependent] children.
  S 25. Paragraph 2 of subsection (a) of section 4303 of  the  insurance
law,  as added by chapter 705 of the laws of 1996, is amended to read as
follows:
  (2) (A) For services to  treat  an  emergency  condition  in  hospital
facilities[.]:
  (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION;
  (II)  REGARDLESS  OF  WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH
SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES;
  (III) IF THE EMERGENCY SERVICES ARE PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION
ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE  REQUIREMENTS  OR  LIMITA-
TIONS  THAT  APPLY  TO  EMERGENCY  SERVICES  RECEIVED FROM PARTICIPATING
PROVIDERS; AND
  (IV) IF THE EMERGENCY SERVICES ARE  PROVIDED  BY  A  NON-PARTICIPATING
PROVIDER,  THE  COST-SHARING  REQUIREMENT  (EXPRESSED  AS A COPAYMENT OR
COINSURANCE) SHALL BE THE SAME REQUIREMENT  THAT  WOULD  APPLY  IF  SUCH
SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER.
  (B)  ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE
ACT, 42 U.S.C.  S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE
REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT  TO  COVERAGE  OF  EMERGENCY
SERVICES  SHALL  BE  APPLICABLE  TO EVERY CONTRACT SUBJECT TO THIS PARA-
GRAPH.
  (C) For the purpose of this provision, "emergency condition"  means  a
medical  or  behavioral  condition[, the onset of which is sudden,] that
manifests itself by ACUTE symptoms  of  sufficient  severity,  including
severe  pain, SUCH that a prudent layperson, possessing an average know-
ledge of medicine and health, could reasonably  expect  the  absence  of
immediate medical attention to result in [(A)] (I) placing the health of
the  person afflicted with such condition in serious jeopardy, or in the
case of a behavioral condition placing the  health  of  such  person  or
others  in  serious  jeopardy[, or (B)]; (II) serious impairment to such
person's bodily functions; [(C)] (III) serious dysfunction of any bodily

S. 5800                            18

organ or part of such person; [or (D)]  (IV)  serious  disfigurement  of
such  person;  OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III)
OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  (D)  FOR  THE  PURPOSE  OF THIS PROVISION, "EMERGENCY SERVICES" MEANS,
WITH RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL SCREENING EXAMINA-
TION AS REQUIRED UNDER SECTION 1867  OF  THE  SOCIAL  SECURITY  ACT,  42
U.S.C. S 1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPART-
MENT  OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO
THE EMERGENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY  MEDICAL  CONDITION;
AND  (II)  WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE
AT THE HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT  AS  ARE
REQUIRED  UNDER  SECTION  1867  OF THE SOCIAL SECURITY ACT, 42 U.S.C.  S
1395DD, TO STABILIZE THE PATIENT.
  (E) FOR THE PURPOSE OF THIS  PROVISION,  "TO  STABILIZE"  MEANS,  WITH
RESPECT  TO AN EMERGENCY CONDITION, TO PROVIDE SUCH MEDICAL TREATMENT OF
THE CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN  REASONABLE  MEDICAL
PROBABILITY,  THAT  NO MATERIAL DETERIORATION OF THE CONDITION IS LIKELY
TO RESULT FROM OR OCCUR DURING THE TRANSFER OF  THE  SUBSCRIBER  FROM  A
FACILITY OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA).
  S  26. Subsection (j) of section 4303 of the insurance law, as amended
by chapter 728 of the laws of 1993, is amended to read as follows:
  (j)(1) A health  service  corporation  or  medical  expense  indemnity
corporation  [which]  THAT  provides  medical,  major-medical or similar
comprehensive-type  coverage  [must]  SHALL  provide  coverage  for  the
provision of preventive and primary care services.
  (2)  For  purposes  OF  THIS  PARAGRAPH  AND  PARAGRAPH  ONE  of  this
subsection, preventive and primary care services shall mean the  follow-
ing  services  rendered  to  a [dependent] COVERED child of a subscriber
from the date of birth through the attainment of nineteen years of age:
  [(i)] (A) an initial hospital check-up and well-child visits scheduled
in accordance with the prevailing clinical standards of a national asso-
ciation of pediatric physicians designated by the commissioner of health
(except for any standard that would limit  the  specialty  or  forum  of
licensure  of  the  practitioner  providing  the  service other than the
limits under state law). Coverage for such services  rendered  shall  be
provided  only to the extent that such services are provided by or under
the supervision of a physician, or  other  professional  licensed  under
article  one  hundred  thirty-nine  of  the education law whose scope of
practice pursuant to such law includes  the  authority  to  provide  the
specified  services.  Coverage  shall  be  provided  for  such  services
rendered in a hospital, as defined in section twenty-eight  hundred  one
of  the  public  health  law,  or  in  an office of a physician or other
professional licensed under  article  one  hundred  thirty-nine  of  the
education  law whose scope of practice pursuant to such law includes the
authority to provide the specified services,
  [(ii)] (B) at each visit, services in accordance with  the  prevailing
clinical  standards  of such designated association, including a medical
history, a  complete  physical  examination,  developmental  assessment,
anticipatory  guidance,  appropriate  immunizations and laboratory tests
which tests are ordered at the time of the visit and  performed  in  the
practitioner's  office, as authorized by law, or in a clinical laborato-
ry, and
  [(iii)] (C) necessary immunizations, as determined by the  superinten-
dent  in  consultation with the commissioner of health, consisting of at
least adequate dosages of vaccine against diphtheria,  pertussis,  teta-
nus,  polio,  measles, rubella, mumps, haemophilus influenzae type b and

S. 5800                            19

hepatitis b, which meet the standards  approved  by  the  United  States
public health service for such biological products.
  (D)  Such  coverage  REQUIRED PURSUANT TO THIS PARAGRAPH AND PARAGRAPH
ONE OF THIS SUBSECTION  shall  not  be  subject  to  annual  deductibles
[and/or] OR coinsurance.
  (E)  Such  coverage  REQUIRED PURSUANT TO THIS PARAGRAPH AND PARAGRAPH
ONE OF THIS SUBSECTION shall not restrict or eliminate existing coverage
provided by the contract.
  (3) IN ADDITION TO PARAGRAPH ONE OR  TWO  OF  THIS  SUBSECTION,  EVERY
CONTRACT  THAT  PROVIDES  HOSPITAL,  SURGICAL  OR MEDICAL CARE COVERAGE,
EXCEPT FOR A GRANDFATHERED HEALTH PLAN  UNDER  PARAGRAPH  FOUR  OF  THIS
SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVENTIVE CARE AND
SCREENINGS  FOR  SUBSCRIBERS,  AND SUCH COVERAGE SHALL NOT BE SUBJECT TO
ANNUAL DEDUCTIBLES OR COINSURANCE:
  (A) EVIDENCE-BASED ITEMS OR SERVICES FOR PREVENTIVE CARE  AND  SCREEN-
INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN-
DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE;
  (B)  IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI-
SORY COMMITTEE ON IMMUNIZATION PRACTICES  OF  THE  CENTERS  FOR  DISEASE
CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED;
  (C)  WITH  RESPECT  TO  CHILDREN,  INCLUDING  INFANTS AND ADOLESCENTS,
EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE-
HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN-
ISTRATION; AND
  (D) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN-
INGS NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AND AS PROVIDED
FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE  HEALTH  RESOURCES  AND
SERVICES ADMINISTRATION.
  (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE  PROVIDED  BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED
ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR  AS  LONG  AS  THE  COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  27. Subsection (p) of section 4303 of the insurance law, as amended
by chapter 554 of the laws of 2002, is amended to read as follows:
  (p) (1) A medical expense indemnity corporation,  a  hospital  service
corporation or a health service corporation [which] THAT provides cover-
age  for  hospital, surgical or medical care shall provide the following
coverage for mammography screening for occult breast cancer:
  (A) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or  who  have  a
first degree relative with a prior history of breast cancer;
  (B)  a  single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive; and
  (C) an annual mammogram for covered persons aged forty and older.
  (D) The coverage required in this paragraph OR PARAGRAPH TWO  OF  THIS
SUBSECTION  may  be subject to annual deductibles and coinsurance as may
be deemed appropriate by the superintendent and as are  consistent  with
those established for other benefits within a given [policy] CONTRACT.
  (2)  [In no event shall coverage pursuant to this section include more
than one annual screening.
  (3)] For purposes OF PARAGRAPH ONE  of  this  subsection,  mammography
screening  means  an  X-ray  examination  of  the breast using dedicated
equipment, including X-ray tube, filter,  compression  device,  screens,
films  and cassettes, with an average glandular radiation dose less than
0.5 rem per view per breast.

S. 5800                            20

  (3) IN ADDITION TO PARAGRAPH ONE OR  TWO  OF  THIS  SUBSECTION,  EVERY
CONTRACT  THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE,
EXCEPT FOR A GRANDFATHERED HEALTH PLAN  UNDER  PARAGRAPH  FOUR  OF  THIS
SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING MAMMOGRAPHY SCREEN-
ING  SERVICES,  AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCT-
IBLES OR COINSURANCE:
  (A) EVIDENCE-BASED ITEMS OR SERVICES  FOR  MAMMOGRAPHY  THAT  HAVE  IN
EFFECT  A  RATING  OF  'A'  OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN-
INGS FOR MAMMOGRAPHY NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH
AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE  HEALTH
RESOURCES AND SERVICES ADMINISTRATION.
  (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE  PROVIDED  BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED
ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR  AS  LONG  AS  THE  COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  28. Subsection (t) of section 4303 of the insurance law, as amended
by chapter 43 of the laws of 1993 and paragraph 1 as amended by  chapter
554 of the laws of 2002, is amended to read as follows:
  (t)  (1)  A  medical expense indemnity corporation, a hospital service
corporation or a health service corporation [which] THAT provides cover-
age for hospital, surgical, or medical care shall provide  coverage  for
an  annual  cervical  cytology  screening  for  cervical  cancer and its
precursor states for  women  aged  eighteen  and  older.  Such  coverage
REQUIRED  BY  THIS  PARAGRAPH  may  be subject to annual deductibles and
coinsurance as may be deemed appropriate by the  superintendent  and  as
are  consistent with those established for other benefits within a given
contract.
  (2) For purposes OF PARAGRAPH ONE of this subsection, cervical cytolo-
gy screening shall include an annual pelvic examination, collection  and
preparation  of  a  Pap  smear,  and  laboratory and diagnostic services
provided in connection with examining and evaluating the Pap smear.
  (3) IN ADDITION TO PARAGRAPH ONE OR  TWO  OF  THIS  SUBSECTION,  EVERY
CONTRACT  THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE,
EXCEPT FOR A GRANDFATHERED HEALTH PLAN  UNDER  PARAGRAPH  FOUR  OF  THIS
SUBSECTION,  SHALL  PROVIDE COVERAGE FOR THE FOLLOWING CERVICAL CYTOLOGY
SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT  BE  SUBJECT  TO  ANNUAL
DEDUCTIBLES OR COINSURANCE:
  (A)  EVIDENCE-BASED  ITEMS OR SERVICES FOR CERVICAL CYTOLOGY THAT HAVE
IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS  OF  THE
UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN-
INGS  FOR  CERVICAL  CYTOLOGY  NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS
PARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES  SUPPORTED  BY
THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE  PROVIDED  BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED
ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR  AS  LONG  AS  THE  COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S  29. Paragraph 5 of subsection (aa) of section 4303 of the insurance
law, as added by chapter 506 of the laws of 2001, is amended to read  as
follows:
  (5) As used in this subsection:

S. 5800                            21

  (A)  "Prehospital  emergency medical services" means the prompt evalu-
ation and treatment of an emergency medical condition,  and/or  non-air-
borne  transportation  of  the  patient to a hospital; provided however,
where the patient utilizes non-air-borne emergency transportation pursu-
ant to this subsection, reimbursement [will] SHALL be based on whether a
prudent  layperson,  possessing  an  average  knowledge  of medicine and
health, could reasonably expect the absence of  such  transportation  to
result  in  (i)  placing  the  health  of the person afflicted with such
condition in serious jeopardy, or in the case of a behavioral  condition
placing  the  health  of such person or others in serious jeopardy; (ii)
serious impairment to such  person's  bodily  functions;  (iii)  serious
dysfunction  of any bodily organ or part of such person; [or] (iv) seri-
ous disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE
(I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  (B) "Emergency condition" means a medical  or  behavioral  condition[,
the  onset  of which is sudden,] that manifests itself by ACUTE symptoms
of sufficient severity, including  severe  pain,  SUCH  that  a  prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably  expect  the absence of immediate medical attention to result
in (i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition, placing  the
health  of  such  person  or  others  in  serious jeopardy; (ii) serious
impairment to such person's bodily functions; (iii) serious  dysfunction
of any bodily organ or part of such person; [or] (iv) serious disfigure-
ment of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR
(III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  S  30.  Subsection (bb) of section 4303 of the insurance law, as added
by chapter 554 of the laws of 2002, is amended to read as follows:
  (bb) A health service corporation or a medical service expense  indem-
nity  corporation [which] THAT provides major medical or similar compre-
hensive-type coverage shall  provide  such  coverage  for  bone  mineral
density  measurements  or tests, and if such contract otherwise includes
coverage for prescription drugs,  drugs  and  devices  approved  by  the
federal  food and drug administration or generic equivalents as approved
substitutes. In determining appropriate coverage provided by [this para-
graph] PARAGRAPHS ONE, TWO AND THREE OF THIS SUBSECTION, the insurer  or
health  maintenance  organization  shall  adopt  standards  [which] THAT
include the criteria of the federal [medicare] MEDICARE program and  the
criteria  of  the  national  institutes  of  health for the detection of
osteoporosis, provided that such coverage shall be further determined as
follows:
  (1) For purposes OF PARAGRAPHS TWO AND THREE of this subsection,  bone
mineral  density  measurements or tests, drugs and devices shall include
those covered under the criteria  of  the  federal  [medicare]  MEDICARE
program as well as those in accordance with the criteria of the national
institutes of health, including, as consistent with such criteria, dual-
energy x-ray absorptiometry.
  (2)  For purposes OF PARAGRAPHS ONE AND THREE of this subsection, bone
mineral density measurements  or  tests,  drugs  and  devices  shall  be
covered  for  individuals  meeting the criteria for coverage, consistent
with the criteria under the federal [medicare] MEDICARE program  or  the
criteria  of  the  national  institutes of health; provided that, to the
extent consistent with such criteria, individuals qualifying for  cover-
age shall, at a minimum, include individuals:
  (i)  previously  diagnosed  as  having osteoporosis or having a family
history of osteoporosis; or

S. 5800                            22

  (ii) with symptoms or conditions indicative of the  presence,  or  the
significant risk, of osteoporosis; or
  (iii) on a prescribed drug regimen posing a significant risk of osteo-
porosis; or
  (iv)  with  lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or
  (v) with such age, gender and/or other  physiological  characteristics
which pose a significant risk for osteoporosis.
  (3)  Such  coverage  REQUIRED PURSUANT TO PARAGRAPH ONE OR TWO OF THIS
SUBSECTION may be subject to annual deductibles and coinsurance  as  may
be  deemed  appropriate by the superintendent and as are consistent with
those established for other benefits within a given policy.
  (4) IN ADDITION TO PARAGRAPH ONE, TWO OR  THREE  OF  THIS  SUBSECTION,
EVERY  CONTRACT  THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVER-
AGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER PARAGRAPH FIVE OF THIS
SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING ITEMS  OR  SERVICES
FOR  BONE  MINERAL  DENSITY,  AND  SUCH COVERAGE SHALL NOT BE SUBJECT TO
ANNUAL DEDUCTIBLES OR COINSURANCE:
  (A) EVIDENCE-BASED ITEMS OR SERVICES FOR  BONE  MINERAL  DENSITY  THAT
HAVE  IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF
THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN-
INGS FOR BONE MINERAL DENSITY NOT DESCRIBED IN SUBPARAGRAPH (A) OF  THIS
PARAGRAPH  AND  AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY
THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (5) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL  WAS  ENROLLED
ON  MARCH  TWENTY-THIRD,  TWO  THOUSAND  TEN FOR AS LONG AS THE COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 31. Paragraphs 1 and 3 of subsection (d)  of  section  4304  of  the
insurance law, paragraph 1 as amended by chapter 240 of the laws of 2009
and  paragraph 3 as added by chapter 93 of the laws of 1989, are amended
to read as follows:
  (1) (A) No contract issued pursuant to this section shall entitle more
than one person to benefits except that a contract issued and marked  as
a  "family  contract"  may provide that benefits will be furnished to [a
husband and wife, or husband, wife and their dependent  child  or  chil-
dren,  or]  THE CONTRACT HOLDER, SPOUSE, DEPENDENT CHILD OR CHILDREN, OR
OTHER PERSON CHIEFLY DEPENDENT UPON THE CONTRACT HOLDER PROVIDED THAT:
  (I) A "FAMILY CONTRACT" MAY PROVIDE COVERAGE TO any child or  children
not over nineteen years of age, provided that an unmarried student at an
accredited  institution  of learning may be considered a dependent until
[he] THE CHILD becomes twenty-three years of age, AND provided ALSO that
the coverage of any such "family contract" may include, at the option of
the [insurer] CORPORATION, any unmarried child until attaining age twen-
ty-five[, and provided also that the]. HOWEVER, A "FAMILY  CONTRACT"  OF
HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT
PROVIDES  COVERAGE FOR DEPENDENT CHILDREN SHALL PROVIDE SUCH COVERAGE TO
A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF AGE TWENTY-SIX  WITHOUT
REGARD  TO  FINANCIAL  DEPENDENCE,  RESIDENCY WITH THE CONTRACT  HOLDER,
STUDENT STATUS, OR EMPLOYMENT.
  (II) THE coverage of any such  "family  contract"  shall  include  any
other  unmarried child, regardless of age, who is incapable of self-sus-
taining employment by reason of mental illness, developmental  disabili-
ty,  mental  retardation, as defined in the mental hygiene law, or phys-

S. 5800                            23

ical handicap and who became so incapable prior to attainment of the age
at which [dependent] coverage would otherwise terminate[, so  that  such
child may be considered a dependent].
  (B)  In addition to the requirements of subparagraph (A) of this para-
graph, every corporation issuing a  contract  OF  HOSPITAL,  MEDICAL  OR
SURGICAL  EXPENSE INSURANCE that provides coverage for [dependent] chil-
dren must make available and if requested by the contractholder,  extend
coverage  under  the  contract to an unmarried child through age twenty-
nine, without regard to financial dependence who is not  insured  by  or
eligible  for coverage under any [employee] EMPLOYER health benefit plan
as an employee or member,  whether  insured  or  self-insured,  and  who
lives,  works  or  resides  in New York state or the service area of the
corporation. Such coverage shall be made available at the  inception  of
all  new contracts, [at the first anniversary date of a policy following
the effective date of  this  subparagraph,]  and  for  group  remittance
contracts at any anniversary date. Written notice of the availability of
such  coverage  shall  be  delivered  to the contractholder prior to the
inception of such [group] contract, [thirty  days  prior  to  the  first
anniversary  date  of  a  policy  following  the  effective date of this
subparagraph,] and for group remittance contracts annually thereafter.
  (C) Notwithstanding any rule, regulation or law to the  contrary,  any
"family  contract"  shall  provide  that  coverage  of  newborn infants,
including newly born infants adopted by the [insured or]  subscriber  if
such  [insured  or] subscriber takes physical custody of the infant upon
such infant's release from the hospital and files a petition pursuant to
section one hundred fifteen-c of the domestic relations law within thir-
ty days of birth; and provided further that no notice of  revocation  to
the adoption has been filed pursuant to section one hundred fifteen-b of
the  domestic  relations  law  and  consent to the adoption has not been
revoked, shall be effective from the moment of birth for injury or sick-
ness including the necessary care and treatment of  medically  diagnosed
congenital  defects  and  birth abnormalities including premature birth,
except that in cases of adoption, coverage of the initial hospital  stay
shall not be required where a birth parent has insurance coverage avail-
able for the infant's care. This provision regarding coverage of newborn
infants  shall not apply to two person coverage. In the case of individ-
ual or two person coverages the corporation must also permit the  person
to  whom  the  [policy]  CONTRACT  is  issued  to elect such coverage of
newborn infants from the moment of birth. If notification and/or payment
of an additional premium or contribution is required  to  make  coverage
effective  for  a  newborn  infant,  the  coverage may provide that such
notice and/or payment be made within no less than thirty days of the day
of birth to make coverage effective  from  the  moment  of  birth.  This
election shall not be required in the case of student insurance or where
the  group remitting agent's plan does not provide coverage for [depend-
ent] children.
  (3) Coverage of an unmarried dependent child who is incapable of self-
sustaining employment by reason of mental illness,  developmental  disa-
bility  or  mental retardation, as defined in the mental hygiene law, or
physical handicap and who became so incapable prior to attainment of the
age at which [dependent] coverage would otherwise terminate and  who  is
chiefly  dependent upon the contract holder for support and maintenance,
shall not terminate while the [policy] CONTRACT remains in force and the
[dependent] CHILD remains  in  such  condition,  if  the  [policyholder]
CONTRACT HOLDER has within thirty-one days of such [dependent's] CHILD'S

S. 5800                            24

attainment  of  the  limiting  age submitted proof of such [dependent's]
CHILD'S incapacity as described herein.
  S  32.  Subsection (e) of section 4304 of the insurance law is amended
by adding a new paragraph 5 to read as follows:
  (5) FOR PURPOSES  OF  THIS  SUBSECTION,  THE  TERM  "DEPENDENT"  SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (D) OF THIS SECTION.
  S  33.  Paragraph 5 of subsection (k) of section 4304 of the insurance
law, as added by chapter 236 of the laws of 2009,  is  renumbered  para-
graph 6 and a new paragraph 7 is added to read as follows:
  (7)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (D) OF THIS SECTION.
  S 34. Paragraphs 1 and 2 of subsection (m)  of  section  4304  of  the
insurance  law, as added by chapter 240 of the laws of 2009, are amended
to read as follows:
  (1) As used in this subsection, ["dependent child"] "CHILD"  means  an
unmarried child through age twenty-nine of an employee or member insured
under  a  group  remittance  contract  OF  HOSPITAL, MEDICAL OR SURGICAL
EXPENSE INSURANCE,  regardless  of  financial  dependence,  who  is  not
insured by or eligible for coverage under any [employee] EMPLOYER health
benefit  plan AS AN EMPLOYEE OR MEMBER, whether insured or self-insured,
and who lives, works or resides in New York state or the service area of
the corporation and who is not covered under title XVIII of  the  United
States Social Security Act (Medicare).
  (2) In addition to the conversion privilege afforded by subsection (e)
of  this  section and the continuation privilege afforded by subsections
(e) and (k) of this section,  a  hospital  service,  health  service  or
medical  expense  corporation  or  health  maintenance organization that
provides HOSPITAL, MEDICAL OR SURGICAL EXPENSE  INSURANCE  coverage  for
which  the  premiums  are  paid  by  the remitting agent of a group that
provides [dependent] coverage OF A CHILD that terminates at a  specified
age  shall,  upon  application  of  the  employee, member or [dependent]
child, as set forth in subparagraph (B)  [or  (C)]  of  this  paragraph,
provide  coverage  to the [dependent] child after that specified age and
through age twenty-nine without evidence of insurability, subject to all
of the terms and conditions of the group  remittance  contract  and  the
following:
  (A)  An  employer shall not be required to pay all or part of the cost
of  coverage  for  a  [dependent]  child  provided  pursuant   to   this
subsection;
  (B)  An  employee,  member  or  [dependent]  child who wishes to elect
continuation of coverage pursuant to this subsection shall  request  the
continuation in writing:
  (i)  within  sixty  days  following  the date coverage would otherwise
terminate due to reaching the specified  age  set  forth  in  the  group
contract;
  (ii)  within sixty days after meeting the requirements for [dependent]
child status set forth in paragraph one of this subsection when coverage
for the [dependent] child previously terminated; or
  (iii) during an annual thirty-day open enrollment period as  described
in the contract.
  (C) [For twelve months after the effective date of this subsection, an
employee,  member  or dependent child may elect prospective continuation
coverage under this subsection for  a  dependent  child  whose  coverage
terminated under the terms of the group remittance contract prior to the
initial effective date of this subsection;

S. 5800                            25

  (D)] An employee, member or [dependent] child electing continuation as
described  in  this subsection shall pay to the group remitting agent or
employer, but not more frequently than on a monthly  basis  in  advance,
the  amount  of  the  required  premium  payment on the due date of each
payment.  The  written election of continuation, together with the first
premium payment required to establish premium payment on a monthly basis
in advance, shall be given to the  group  remitting  agent  or  employer
within the time periods set forth in [subparagraphs (B) and (C)] SUBPAR-
AGRAPH (B) of this paragraph. Any premium received within the thirty-day
period after the due date shall be considered timely;
  [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
days of the date the [dependent] child would otherwise lose coverage due
to reaching a specified age, the  effective  date  of  the  continuation
coverage shall be the date coverage would have otherwise terminated. For
any  [dependent] child electing to resume coverage during an annual open
enrollment period [or during the twelve-month  initial  open  enrollment
period  described  in subparagraph (C) of this paragraph], the effective
date of the continuation coverage shall be  prospective  no  later  than
thirty days after the election and payment of first premium;
  [(F)] (E) Coverage for a [dependent] child pursuant to this subsection
shall  consist of coverage that is identical to the coverage provided to
the employee or  member  parent.  If  coverage  is  modified  under  the
contract  for any group of similarly situated employees or members, then
the coverage shall also be modified in the same manner for any  [depend-
ent] child;
  [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
following:
  (i) the date the [dependent] child no longer meets the requirements of
paragraph one of this subsection;
  (ii) the end of the period for which premium payments  were  made,  if
there  is a failure to make payment of a required premium payment within
the period of grace described in subparagraph [(D)] (C)  of  this  para-
graph; or
  (iii)  the  date  on which the group remittance contract is terminated
and not replaced by coverage under another  group  or  group  remittance
contract; and
  [(H)]  (G)  The  corporation  or health maintenance organization shall
provide written notification of the continuation privilege described  in
this  subsection and the time period in which to request continuation to
the employee or member:
  (i) in each certificate of coverage; AND
  (ii) at least sixty days prior to termination at the specified age  as
provided in the contract[;
  (iii)  within  thirty  days  of the effective date of this subsection,
with respect to information concerning a dependent child's  opportunity,
for twelve months after the effective date of this subsection, to make a
written election to obtain coverage under a contract pursuant to subpar-
agraph (C) of this paragraph].
  S  35.  Paragraph 1 of subsection (c) of section 4305 of the insurance
law, as amended by chapter 240 of the laws of 2009, is amended  to  read
as follows:
  (1)(A)  Any  such contract may provide that benefits will be furnished
to a member of a covered group, for  [himself]  THE  MEMBER,  [his]  THE
MEMBER'S  spouse,  [his]  child  or  children,  or other persons chiefly
dependent upon [him] THE MEMBER for support  and  maintenance;  provided
that:

S. 5800                            26

  (I)  A  CONTRACT  OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG
EXPENSE INSURANCE THAT PROVIDES COVERAGE FOR CHILDREN SHALL PROVIDE SUCH
COVERAGE TO A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF  AGE  TWEN-
TY-SIX,  WITHOUT  REGARD  TO  FINANCIAL  DEPENDENCE,  RESIDENCY WITH THE
MEMBER,  STUDENT  STATUS,  OR  EMPLOYMENT,  EXCEPT  A CONTRACT THAT IS A
GRANDFATHERED HEALTH PLAN MAY, FOR PLAN YEARS BEGINNING  BEFORE  JANUARY
FIRST,  TWO  THOUSAND FOURTEEN, EXCLUDE COVERAGE OF AN ADULT CHILD UNDER
AGE TWENTY-SIX WHO IS ELIGIBLE TO ENROLL IN AN EMPLOYER-SPONSORED HEALTH
PLAN OTHER THAN A GROUP HEALTH PLAN OF A PARENT. FOR  PURPOSES  OF  THIS
ITEM,  "GRANDFATHERED  HEALTH  PLAN" MEANS COVERAGE PROVIDED BY A CORPO-
RATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON  MARCH  TWENTY-THIRD,  TWO
THOUSAND  TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS
IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
S 18011(E); AND
  (II) a contract under which coverage [of  a  dependent  of  a  member]
terminates  at a specified age shall, with respect to an unmarried child
who is incapable of  self-sustaining  employment  by  reason  of  mental
illness, developmental disability, mental retardation, as defined in the
mental  hygiene  law,  or  physical handicap and who became so incapable
prior to attainment of the  age  at  which  [dependent]  coverage  would
otherwise  terminate  and  who is chiefly dependent upon such member for
support and maintenance, not so terminate while the contract remains  in
force and the [dependent] CHILD remains in such condition, if the member
has  within  thirty-one days of such [dependent's] CHILD'S attainment of
the termination age submitted proof of such [dependent's] CHILD'S  inca-
pacity as described herein.
  (B)  In addition to the requirements of subparagraph (A) of this para-
graph, every corporation issuing a group contract OF  HOSPITAL,  MEDICAL
OR  SURGICAL  EXPENSE  INSURANCE  pursuant to this section that provides
coverage for [dependent] children, must make available and if  requested
by  the contractholder, extend coverage under that contract to an unmar-
ried child through age twenty-nine, without regard to financial  depend-
ence who is not insured by or eligible for coverage under any [employee]
EMPLOYER  health  benefit plan as an employee or member, whether insured
or self-insured, and who lives, works or resides in New  York  state  or
the  service area of the corporation. Such coverage shall be made avail-
able at the inception of all new contracts and with respect to all other
contracts at any anniversary date. Written notice of the availability of
such coverage shall be delivered to  the  contractholder  prior  to  the
inception of such group contract and annually thereafter.
  (C)  Notwithstanding  any rule, regulation or law to the contrary, any
contract under which a member elects coverage for [himself, his  spouse,
his]  THE MEMBER, THE MEMBER'S SPOUSE, children or other persons chiefly
dependent upon [him]  THE  MEMBER  for  support  and  maintenance  shall
provide  that  coverage of newborn infants, including newly born infants
adopted by the [insured  or  subscriber]  MEMBER  if  such  [insured  or
subscriber]  MEMBER  takes  physical  custody  of  the  infant upon such
infant's release from the hospital and  files  a  petition  pursuant  to
section one hundred fifteen-c of the domestic relations law within thir-
ty  days  of birth; and provided further that no notice of revocation to
the adoption has been filed pursuant to section one hundred fifteen-b of
the domestic relations law and consent to  the  adoption  has  not  been
revoked, shall be effective from the moment of birth for injury or sick-
ness  including  the necessary care and treatment of medically diagnosed
congenital defects and birth abnormalities  including  premature  birth,
except  that in cases of adoption, coverage of the initial hospital stay

S. 5800                            27

shall not be required where a birth parent has insurance coverage avail-
able for the infant's care. This provision regarding coverage of newborn
infants shall not apply to two person coverage. In the case of  individ-
ual  or two person coverages the corporation must also permit the person
to whom the certificate is issued to  elect  such  coverage  of  newborn
infants  from  the moment of birth. If notification and/or payment of an
additional premium or contribution is required to make  coverage  effec-
tive  for  a  newborn  infant, the coverage may provide that such notice
and/or payment be made within no less than thirty days  of  the  day  of
birth to make coverage effective from the moment of birth. This election
shall  not  be  required  in  the case of student insurance or where the
group's plan does not provide coverage for [dependent] children.
  S 36. Subsection (d) of section 4305 of the insurance law  is  amended
by adding a new paragraph 5 to read as follows:
  (5)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION.
  S 37. Subsection (e) of section 4305 of the insurance law  is  amended
by adding a new paragraph 9 to read as follows:
  (9)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION.
  S 38. Subsection (k) of section 4305 of the insurance law  is  amended
by adding a new paragraph 7 to read as follows:
  (7)  FOR  PURPOSES  OF  THIS  SUBSECTION,  THE  TERM "DEPENDENT" SHALL
INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION.
  S 39. Subsection (l) of section 4305 of the insurance law, as added by
chapter 237 of the laws of 2009, is relettered subsection (m) and  para-
graphs  1  and 2 of subsection (l) of section 4305 of the insurance law,
as added by chapter 240 of the laws of 2009,  are  amended  to  read  as
follows:
  (1)  As  used in this subsection, ["dependent child"] "CHILD" means an
unmarried child through age twenty-nine of an employee or member insured
under a group contract OF HOSPITAL, MEDICAL OR SURGICAL  EXPENSE  INSUR-
ANCE,  regardless  of  financial  dependence,  who  is not insured by or
eligible for coverage under any [employee] EMPLOYER health benefit  plan
AS  AN  EMPLOYEE  OR  MEMBER,  whether  insured or self-insured, and who
lives, works or resides in New York state or the  service  area  of  the
corporation  and  who  is  not  covered  under title XVIII of the United
States Social Security Act (Medicare).
  (2) In addition to the conversion privilege afforded by subsection (d)
of this section and the continuation privilege  afforded  by  subsection
(e)  of  this  section,  a  hospital  service, health service or medical
expense corporation or health  maintenance  organization  that  provides
group  HOSPITAL,  MEDICAL  OR  SURGICAL coverage under which [dependent]
coverage OF A CHILD terminates at a specified age shall,  upon  applica-
tion  of  the  employee,  member  or  [dependent] child, as set forth in
subparagraph (B) [or (C)] of this paragraph,  provide  coverage  to  the
[dependent]  child  after that specified age and through age twenty-nine
without evidence of insurability, subject to all of the terms and condi-
tions of the group contract and the following:
  (A) An employer shall not be required to pay all or part of  the  cost
of   coverage   for  a  [dependent]  child  provided  pursuant  to  this
subsection;
  (B) An employee, member or  [dependent]  child  who  wishes  to  elect
continuation  of  coverage pursuant to this subsection shall request the
continuation in writing:

S. 5800                            28

  (i) within sixty days following  the  date  coverage  would  otherwise
terminate  due  to  reaching  the  specified  age set forth in the group
contract;
  (ii)  within sixty days after meeting the requirements for [dependent]
child status set forth in paragraph one of this subsection when coverage
for the [dependent] child previously terminated; or
  (iii) during an annual thirty-day open enrollment period, as described
in the contract;
  (C) [For twelve months after the effective date of this subsection, an
employee, member or dependent child may elect  prospective  continuation
coverage  under  this  subsection  for  a dependent child whose coverage
terminated under the terms of the group contract prior to the  effective
date of this subsection;
  (D)] An employee, member or [dependent] child electing continuation as
described  in  this  subsection shall pay to the group contractholder or
employer, but not more frequently than on a monthly  basis  in  advance,
the  amount  of  the  required  premium  payment on the due date of each
payment. The written election of continuation, together with  the  first
premium payment required to establish premium payment on a monthly basis
in advance, shall be given to the group contractholder or employer with-
in  the  time  periods set forth in [subparagraphs (B) and (C)] SUBPARA-
GRAPH (B) of this paragraph. Any premium received within the  thirty-day
period after the due date shall be considered timely;
  [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
days of the date the [dependent] child would otherwise lose coverage due
to reaching a specified age, the  effective  date  of  the  continuation
coverage shall be the date coverage would have otherwise terminated. For
any  [dependent] child electing to resume coverage during an annual open
enrollment period [or during the twelve-month  initial  open  enrollment
period  described  in subparagraph (C) of this paragraph], the effective
date of the continuation coverage shall be  prospective  no  later  than
thirty days after the election and payment of first premium;
  [(F)] (E) Coverage for a [dependent] child pursuant to this subsection
shall  consist of coverage that is identical to the coverage provided to
the employee or  member  parent.  If  coverage  is  modified  under  the
contract  for any group of similarly situated employees or members, then
the coverage shall also be modified in the same manner for any  [depend-
ent] child;
  [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
following:
  (i) the date the [dependent] child no longer meets the requirements of
paragraph one of this subsection;
  (ii) the end of the period for which premium payments  were  made,  if
there  is a failure to make payment of a required premium payment within
the period of grace described in subparagraph [(D)] (C)  of  this  para-
graph; or
  (iii)  the  date  on  which  the  group contract is terminated and not
replaced by coverage under another group contract; and
  [(H)] (G) The corporation or  health  maintenance  organization  shall
provide  written notification of the continuation privilege described in
this subsection and the time period in which to request continuation  to
the employee or member:
  (i) in each certificate of coverage; AND
  (ii)  at least sixty days prior to termination at the specified age as
provided in the contract[;

S. 5800                            29

  (iii) within thirty days of the effective  date  of  this  subsection,
with  respect to information concerning a dependent child's opportunity,
for twelve months after the effective date of this subsection, to make a
written election to obtain coverage under a contract pursuant to subpar-
agraph (C) of this paragraph].
  S  40. Section 4306-b of the insurance law, as added by chapter 554 of
the laws of 2002, is amended to read as follows:
  S 4306-b. Primary and preventive obstetric and gynecologic care.   (a)
No  corporation  subject  to  the  provisions  of  this article shall by
contract, written policy or procedure limit a female subscriber's direct
access to primary and preventive  obstetric  and  gynecologic  services,
INCLUDING  ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINA-
TIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from  a  qualified
provider  of  such  services of her choice from within the plan [to less
than two examinations annually for such services] or [to] FOR  any  care
related  to  a  pregnancy[.  In addition, no corporation subject to this
article shall by contract, written  policy  or  procedure  limit  direct
access  to  primary  and  preventive  obstetric and gynecologic services
required as a result of such annual examinations or as a  result  of  an
acute gynecologic condition], provided that: (1) such qualified provider
discusses such services and treatment plan with the subscriber's primary
care   practitioner   in   accordance   with  the  requirements  of  the
corporation; AND (2) SUCH QUALIFIED PROVIDER AGREES  TO  ADHERE  TO  THE
CORPORATION'S  POLICIES  AND PROCEDURES, INCLUDING ANY APPLICABLE PROCE-
DURES REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR SERVICES
OTHER THAN OBSTETRIC AND GYNECOLOGIC SERVICES RENDERED BY SUCH QUALIFIED
PROVIDER, AND AGREES TO PROVIDE SERVICES PURSUANT TO  A  TREATMENT  PLAN
(IF ANY) APPROVED BY THE CORPORATION.
  (b)  A  CORPORATION SHALL TREAT THE PROVISION OF OBSTETRIC AND GYNECO-
LOGIC CARE, AND THE ORDERING OF RELATED OBSTETRIC AND GYNECOLOGIC  ITEMS
AND  SERVICES, PURSUANT TO THE DIRECT ACCESS DESCRIBED IN SUBSECTION (A)
OF THIS SECTION BY A PARTICIPATING QUALIFIED PROVIDER OF SUCH  SERVICES,
AS THE AUTHORIZATION OF THE PRIMARY CARE PROVIDER.
  (C) It shall be the duty of the administrative officer or other person
in  charge of each corporation subject to the provisions of this article
to advise each female subscriber, in writing, of the provisions of  this
section.
  S  41.  The insurance law is amended by adding a new section 4306-d to
read as follows:
  S 4306-D. CHOICE OF  HEALTH  CARE  PROVIDER.  A  CORPORATION  THAT  IS
SUBJECT  TO  THE PROVISIONS OF THIS ARTICLE AND REQUIRES OR PROVIDES FOR
DESIGNATION BY A SUBSCRIBER OF A  PARTICIPATING  PRIMARY  CARE  PROVIDER
SHALL  PERMIT THE SUBSCRIBER TO DESIGNATE ANY PARTICIPATING PRIMARY CARE
PROVIDER WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL, AND IN THE CASE  OF
A CHILD, SHALL PERMIT THE SUBSCRIBER TO DESIGNATE A PHYSICIAN (ALLOPATH-
IC  OR OSTEOPATHIC) WHO SPECIALIZES IN PEDIATRICS AS THE CHILD'S PRIMARY
CARE PROVIDER IF SUCH PROVIDER PARTICIPATES IN THE NETWORK OF THE CORPO-
RATION.
  S 42. The insurance law is amended by adding a new section  4306-e  to
read as follows:
  S  4306-E.  PROHIBITION  ON  LIFETIME AND ANNUAL LIMITS.  (A) A CORPO-
RATION SHALL NOT ESTABLISH A LIFETIME LIMIT  ON  THE  DOLLAR  AMOUNT  OF
ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET CONTRACT OF
HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE.
  (B)  A  CORPORATION  SHALL NOT ESTABLISH AN ANNUAL LIMIT ON THE DOLLAR
AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP  OR  BLANKET

S. 5800                            30

CONTRACT  OF  HOSPITAL,  MEDICAL,  SURGICAL OR PRESCRIPTION DRUG EXPENSE
INSURANCE FOR CONTRACT YEARS BEGINNING ON AND  AFTER  JANUARY  ONE,  TWO
THOUSAND FOURTEEN.
  (C)  FOR  CONTRACT  YEARS BEGINNING PRIOR TO JANUARY ONE, TWO THOUSAND
FOURTEEN, A CORPORATION MAY ESTABLISH RESTRICTED ANNUAL  LIMITS  ON  THE
DOLLAR  AMOUNT  OF  ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR
BLANKET CONTRACT OF HOSPITAL, MEDICAL,  SURGICAL  OR  PRESCRIPTION  DRUG
EXPENSE  INSURANCE  CONSISTENT  WITH  SECTION  2711 OF THE PUBLIC HEALTH
SERVICE ACT, 42 U.S.C. S 300GG-11 OR ANY REGULATIONS THEREUNDER.
  (D) THE REQUIREMENTS OF SUBSECTIONS (B) AND (C) OF THIS SECTION  SHALL
NOT  BE  APPLICABLE  TO  ANY INDIVIDUAL CONTRACT THAT IS A GRANDFATHERED
HEALTH PLAN. FOR PURPOSES OF THIS SECTION, "GRANDFATHERED  HEALTH  PLAN"
MEANS  COVERAGE  PROVIDED  BY  A  CORPORATION IN WHICH AN INDIVIDUAL WAS
ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN  FOR  AS  LONG  AS  THE
COVERAGE  MAINTAINS  GRANDFATHERED  STATUS  IN  ACCORDANCE  WITH SECTION
1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.  S 18011(E).
  (E) FOR PURPOSES OF THIS SECTION, "ESSENTIAL  HEALTH  BENEFITS"  SHALL
HAVE THE MEANING ASCRIBED BY SECTION 1302(B) OF THE AFFORDABLE CARE ACT,
42 U.S.C. S 18022(B).
  S  43. Section 4318 of the insurance law is amended by adding four new
subsections (f), (g), (h) and (i) to read as follows:
  (F) WITH RESPECT TO AN INDIVIDUAL UNDER AGE  NINETEEN,  A  CORPORATION
MAY  NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDIVIDUAL OR
GROUP CONTRACT OF  HOSPITAL,  MEDICAL,  SURGICAL  OR  PRESCRIPTION  DRUG
EXPENSE  INSURANCE  PURSUANT  TO THE REQUIREMENTS OF SECTION 2704 OF THE
PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3,  AS  MADE  EFFECTIVE  BY
SECTION  1255(2)  OF  THE  AFFORDABLE CARE ACT, EXCEPT FOR AN INDIVIDUAL
UNDER AGE NINETEEN COVERED UNDER AN  INDIVIDUAL  CONTRACT  OF  HOSPITAL,
MEDICAL,  SURGICAL  OR  PRESCRIPTION  DRUG  EXPENSE  INSURANCE THAT IS A
GRANDFATHERED HEALTH PLAN.
  (G) BEGINNING  JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN,  PURSUANT  TO
SECTION  2704  OF  THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, A
CORPORATION MAY NOT IMPOSE ANY PRE-EXISTING CONDITION  EXCLUSION  IN  AN
INDIVIDUAL   OR   GROUP  CONTRACT  OF  HOSPITAL,  MEDICAL,  SURGICAL  OR
PRESCRIPTION DRUG EXPENSE INSURANCE EXCEPT  IN  AN  INDIVIDUAL  CONTRACT
THAT IS A GRANDFATHERED HEALTH PLAN.
  (H)  THE REQUIREMENTS OF SUBSECTIONS (F) AND (G) OF THIS SECTION SHALL
ALSO BE APPLICABLE TO A BLANKET CONTRACT OF HOSPITAL, MEDICAL,  SURGICAL
OR PRESCRIPTION DRUG EXPENSE INSURANCE.
  (I) FOR PURPOSES OF SUBSECTIONS (F) AND (G) OF THIS SECTION, "GRANDFA-
THERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN
INDIVIDUAL  WAS  ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS
LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN  ACCORDANCE  WITH
SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 44. Subsection (c) of section 4321 of the insurance law, as added by
chapter 504 of the laws of 1995, is amended to read as follows:
  (c)  The health maintenance organization shall impose a fifteen dollar
copayment on all visits to a physician or other provider with the excep-
tion of visits for pre-natal and post-natal care [or], well child visits
provided pursuant to paragraph two of subsection  (j)  of  section  four
thousand three hundred three of this article, PREVENTIVE HEALTH SERVICES
PROVIDED  PURSUANT  TO  SUBPARAGRAPH (F) OF PARAGRAPH FOUR OF SUBSECTION
(B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-TWO OF  THIS  ARTICLE,
OR  ITEMS  OR  SERVICES  FOR  BONE  MINERAL DENSITY PROVIDED PURSUANT TO
SUBPARAGRAPH (D) OF PARAGRAPH TWENTY-SIX OF SUBSECTION  (B)  OF  SECTION
FOUR  THOUSAND  THREE  HUNDRED  TWENTY-TWO  OF THIS ARTICLE for which no

S. 5800                            31

copayment shall apply. A copayment of fifteen dollars shall  be  imposed
on  equipment,  supplies and self-management education for the treatment
of diabetes. A fifty dollar copayment  shall  be  imposed  on  emergency
services  rendered  in  the  emergency room of a hospital; however, this
copayment  must  be  waived  if  hospital  admission  results.  Surgical
services shall be subject to a copayment of the lesser of twenty percent
of  the  cost  of such services or two hundred dollars per occurrence. A
five hundred dollar copayment shall be  imposed  on  inpatient  hospital
services   per  continuous  hospital  confinement.  Ambulatory  surgical
services shall be subject to a facility copayment charge of seventy-five
dollars. Coinsurance of ten percent shall apply to visits for the  diag-
nosis  and  treatment  of  mental,  nervous  or  emotional  disorders or
ailments.
  S 45. Subparagraphs (D) and (E) of paragraph 4 of  subsection  (b)  of
section 4322 of the insurance law, as amended by chapter 554 of the laws
of  2002,  are  amended  and  a new subparagraph (F) is added to read as
follows:
  (D) mammography screening, as provided in subsection  (p)  of  section
four thousand three hundred three of this article; [and]
  (E)  cervical  cytology  screening  as  provided  in subsection (t) of
section four thousand three hundred three of this article[.]; AND
  (F) FOR A CONTRACT THAT  IS  NOT  A  GRANDFATHERED  HEALTH  PLAN,  THE
FOLLOWING ADDITIONAL PREVENTIVE HEALTH SERVICES:
  (I)  EVIDENCE-BASED  ITEMS OR SERVICES THAT HAVE IN EFFECT A RATING OF
'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED  STATES  PREVEN-
TIVE SERVICES TASK FORCE;
  (II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI-
SORY  COMMITTEE  ON  IMMUNIZATION  PRACTICES  OF THE CENTERS FOR DISEASE
CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED;
  (III) WITH RESPECT TO CHILDREN,  INCLUDING  INFANTS  AND  ADOLESCENTS,
EVIDENCE-INFORMED  PREVENTIVE  CARE  AND  SCREENINGS PROVIDED FOR IN THE
COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND  SERVICES
ADMINISTRATION; AND
  (IV)  WITH  RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE CARE AND
SCREENINGS NOT DESCRIBED  IN  ITEM  (I)  OF  THIS  SUBPARAGRAPH  AND  AS
PROVIDED  FOR  IN  COMPREHENSIVE  GUIDELINES  SUPPORTED  BY  THE  HEALTH
RESOURCES AND SERVICES ADMINISTRATION.
  (V) FOR PURPOSES OF THIS  SUBPARAGRAPH,  "GRANDFATHERED  HEALTH  PLAN"
MEANS  COVERAGE  PROVIDED  BY  A  CORPORATION IN WHICH AN INDIVIDUAL WAS
ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN  FOR  AS  LONG  AS  THE
COVERAGE  MAINTAINS  GRANDFATHERED  STATUS  IN  ACCORDANCE  WITH SECTION
1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 46. Paragraph 26 of subsection (b) of section 4322 of the  insurance
law,  as added by chapter 554 of the laws of 2002, is amended to read as
follows:
  (26) Bone mineral density measurements or tests and, if such  contract
otherwise  includes  coverage  for prescription drugs, drugs and devices
approved by the federal food and drug administration or  generic  equiv-
alents as approved substitutes.
  In determining appropriate coverage provided by SUBPARAGRAPHS (A), (B)
AND  (C)  OF this paragraph, the insurer or health maintenance organiza-
tion shall adopt standards [which] THAT  include  the  criteria  of  the
federal  [medicare]  MEDICARE  program  and the criteria of the national
institutes of health for the detection of  osteoporosis,  provided  that
such coverage shall be further determined as follows:

S. 5800                            32

  (A)  For purposes of SUBPARAGRAPHS (B) AND (C) OF this paragraph, bone
mineral density measurements or tests, drugs and devices  shall  include
those  covered  under  the  criteria  of the federal [medicare] MEDICARE
program as well as  those  in  accordance  with  the  criteria,  of  the
national institutes of health, including, as consistent with such crite-
ria dual-energy x-ray absorptiometry.
  (B)  For purposes of SUBPARAGRAPHS (A) AND (C) OF this paragraph, bone
mineral density measurements  or  tests,  drugs  and  devices  shall  be
covered  for  individuals  meeting  the criteria for coverage consistent
with the criteria under the federal [medicare] MEDICARE program  or  the
criteria  of  the  national  institutes of health; provided that, to the
extent consistent with such criteria, individuals qualifying for  cover-
age shall at a minimum, include individuals:
  (i)  previously  diagnosed  as  having osteoporosis or having a family
history of osteoporosis; or
  (ii) with symptoms or conditions indicative of the  presence,  or  the
significant risk, of osteoporosis; or
  (iii) on a prescribed drug regimen posing a significant risk of osteo-
porosis; or
  (iv)  with  lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or
  (v) with such age, gender and/or other  physiological  characteristics
which pose a significant risk for osteoporosis.
  (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS
PARAGRAPH may be subject to annual deductibles and coinsurance as may be
deemed  appropriate  by  the  superintendent  and as are consistent with
those established for other benefits within a given policy.
  (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR  (C)  OF  THIS  PARAGRAPH,
EXCEPT  FOR  A  GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS
PARAGRAPH, COVERAGE  SHALL  BE  PROVIDED  FOR  THE  FOLLOWING  ITEMS  OR
SERVICES  FOR  BONE  MINERAL  DENSITY,  AND  SUCH  COVERAGE SHALL NOT BE
SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE:
  (I) EVIDENCE-BASED ITEMS OR SERVICES FOR  BONE  MINERAL  DENSITY  THAT
HAVE  IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF
THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND
  (II) WITH RESPECT  TO  WOMEN,  SUCH  ADDITIONAL  PREVENTIVE  CARE  AND
SCREENINGS  FOR  BONE  MINERAL DENSITY NOT DESCRIBED IN ITEM (I) OF THIS
SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE  GUIDELINES  SUPPORTED
BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.
  (E)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL  WAS  ENROLLED
ON  MARCH  TWENTY-THIRD,  TWO  THOUSAND  TEN FOR AS LONG AS THE COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 47. Subsections (c) and (d) of section 4322 of the insurance law, as
added by chapter 504 of the  laws  of  1995,  are  amended  to  read  as
follows:
  (c)  The in-plan benefit system shall impose a ten dollar copayment on
all visits to a physician or other provider with the exception of visits
for pre-natal and post-natal  care  [or],  well  child  visits  provided
pursuant  to  paragraph  two  of subsection (j) of section four thousand
three hundred three of this article, PREVENTIVE HEALTH SERVICES PROVIDED
PURSUANT TO SUBPARAGRAPH (F) OF PARAGRAPH FOUR OF SUBSECTION (B) OF THIS
SECTION OR ITEMS OR SERVICES FOR BONE MINERAL DENSITY PROVIDED  PURSUANT
TO  SUBPARAGRAPH  (D)  OF PARAGRAPH TWENTY-SIX OF SUBSECTION (B) OF THIS
SECTION for which no copayment shall apply. A copayment of  ten  dollars

S. 5800                            33

shall  be  imposed  on equipment, supplies and self-management education
for the treatment of diabetes. Coinsurance of ten percent shall apply to
visits for the diagnosis and treatment of mental, nervous  or  emotional
disorders  or  ailments. A thirty-five dollar copayment shall be imposed
on emergency services rendered in the  emergency  room  of  a  hospital;
however, this copayment must be waived if hospital admission results.
  (d)  The  out-of-plan  benefit  system shall have an annual deductible
established at one thousand dollars per calendar year for an  individual
and  two  thousand  dollars  per year for a family. Coinsurance shall be
established at twenty percent with the health  maintenance  organization
or  insurer paying eighty percent of the usual, customary and reasonable
charges, or eighty percent of the amounts listed on a fee schedule filed
with and approved by the  superintendent  which  provides  a  comparable
level of reimbursement. Coinsurance of ten percent shall apply to outpa-
tient  visits  for  the  diagnosis  and  treatment of mental, nervous or
emotional disorders or ailments. The benefits described in  subparagraph
(F)  of  paragraph  three  and  paragraphs  seventeen  and  eighteen  of
subsection (b) of this section shall not be subject to the deductible or
coinsurance. The benefits described in paragraph nine of subsection  (b)
of  this section shall not be subject to the deductible. The out-of-plan
out-of-pocket maximum deductible and coinsurance shall be established at
three thousand dollars per calendar year  for  an  individual  and  five
thousand  dollars  per calendar year for a family. The out-of-plan life-
time benefit maximum shall  be  established  at  five  hundred  thousand
dollars  FOR BENEFITS THAT ARE NOT ESSENTIAL HEALTH BENEFITS. A LIFETIME
LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS FOR ANY INDIVID-
UAL SHALL NOT BE ESTABLISHED. FOR PURPOSES OF THIS  SUBSECTION,  "ESSEN-
TIAL HEALTH BENEFITS" SHALL HAVE THE MEANING ASCRIBED BY SECTION 1302(B)
OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B).
  S  48.  Paragraphs  13 and 14 of subsection (d) of section 4326 of the
insurance law, as added by chapter 1 of the laws of  1999,  are  amended
and a new paragraph 15 is added to read as follows:
  (13)  blood and blood products furnished in connection with surgery or
inpatient hospital services; [and]
  (14) prescription drugs obtained at a participating pharmacy. In addi-
tion to providing coverage at a participating pharmacy,  health  mainte-
nance  organizations may utilize a mail order prescription drug program.
Health maintenance organizations may provide prescription drugs pursuant
to a drug formulary;  however,  health  maintenance  organizations  must
implement   an   appeals  process  so  that  the  use  of  non-formulary
prescription drugs may be requested by a physician[.]; AND
  (15) FOR A CONTRACT THAT IS  NOT  A  GRANDFATHERED  HEALTH  PLAN,  THE
FOLLOWING ADDITIONAL PREVENTIVE HEALTH SERVICES:
  (A)  EVIDENCE-BASED  ITEMS OR SERVICES THAT HAVE IN EFFECT A RATING OF
'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED  STATES  PREVEN-
TIVE SERVICES TASK FORCE;
  (B)  IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI-
SORY COMMITTEE ON IMMUNIZATION PRACTICES  OF  THE  CENTERS  FOR  DISEASE
CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED;
  (C)  WITH  RESPECT  TO  CHILDREN,  INCLUDING  INFANTS AND ADOLESCENTS,
EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS  PROVIDED  FOR  IN  THE
COMPREHENSIVE  GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES
ADMINISTRATION; AND
  (D) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN-
INGS NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AS PROVIDED FOR

S. 5800                            34

IN COMPREHENSIVE  GUIDELINES  SUPPORTED  BY  THE  HEALTH  RESOURCES  AND
SERVICES ADMINISTRATION.
  (E)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL  WAS  ENROLLED
ON  MARCH  TWENTY-THIRD,  TWO  THOUSAND  TEN FOR AS LONG AS THE COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 49. Paragraphs 6 and 7 of subsection (e)  of  section  4326  of  the
insurance law, as added by chapter 1 of the laws of 1999, are amended to
read as follows:
  (6)  (A)  the maximum coverage for prescription drugs IN AN INDIVIDUAL
CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN  shall  be  three  thousand
dollars per individual in a calendar year; and
  (B) THE MAXIMUM DOLLAR AMOUNT ON COVERAGE FOR PRESCRIPTION DRUGS IN AN
INDIVIDUAL  CONTRACT  THAT  IS NOT A GRANDFATHERED HEALTH PLAN OR IN ANY
GROUP CONTRACT SHALL BE CONSISTENT  WITH  SECTION  2711  OF  THE  PUBLIC
HEALTH SERVICE ACT, 42 U.S.C. S 300GG-11 OR ANY REGULATIONS THEREUNDER.
  (C)  FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS
COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL  WAS  ENROLLED
ON  MARCH  TWENTY-THIRD,  TWO  THOUSAND  TEN FOR AS LONG AS THE COVERAGE
MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E); AND
  (7) all other services shall have a twenty dollar copayment  with  the
exception  of  prenatal  care which shall have a ten dollar copayment OR
PREVENTIVE HEALTH SERVICES PROVIDED PURSUANT  TO  PARAGRAPH  FIFTEEN  OF
SUBSECTION (D) OF THIS SECTION, FOR WHICH NO COPAYMENT SHALL APPLY.
  S 50. Subsection (k) of section 4326 of the insurance law, as added by
chapter 1 of the laws of 1999, is amended to read as follows:
  (k)  (1)  All  coverage  under  a  qualifying  group  health insurance
contract or a qualifying individual health insurance  contract  must  be
subject to a pre-existing condition limitation provision as set forth in
sections  three thousand two hundred thirty-two of this chapter and four
thousand three hundred eighteen of this article, including the crediting
requirements thereunder. The underwriting  of  such  contracts  may  not
involve more than the imposition of a pre-existing condition limitation.
HOWEVER,  AS  PROVIDED IN SECTIONS THREE THOUSAND TWO HUNDRED THIRTY-TWO
OF THIS CHAPTER AND FOUR THOUSAND THREE HUNDRED EIGHTEEN OF  THIS  ARTI-
CLE,  A CORPORATION SHALL NOT IMPOSE A PRE-EXISTING CONDITION LIMITATION
PROVISION ON ANY PERSON UNDER AGE NINETEEN, EXCEPT  MAY  IMPOSE  SUCH  A
LIMITATION  ON  THOSE  PERSONS COVERED BY A QUALIFYING INDIVIDUAL HEALTH
INSURANCE CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN.
  (2) BEGINNING  JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN,  PURSUANT  TO
SECTION  2704  OF  THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, A
CORPORATION SHALL NOT IMPOSE ANY PRE-EXISTING CONDITION LIMITATION IN  A
QUALIFYING  GROUP  HEALTH  INSURANCE CONTRACT OR A QUALIFYING INDIVIDUAL
HEALTH INSURANCE CONTRACT EXCEPT MAY IMPOSE SUCH A LIMITATION IN A QUAL-
IFYING INDIVIDUAL HEALTH INSURANCE  CONTRACT  THAT  IS  A  GRANDFATHERED
HEALTH PLAN.
  (3) FOR PURPOSES OF PARAGRAPHS ONE AND TWO OF THIS SUBSECTION, "GRAND-
FATHERED  HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH
AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND  TEN  FOR
AS  LONG  AS  THE  COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE
WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
  S 51. Subsection (c) of section 4900 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:

S. 5800                            35

  (c) "Emergency condition" means a  medical  or  behavioral  condition,
[the  onset of which is sudden,] that manifests itself by ACUTE symptoms
of sufficient severity, including  severe  pain,  SUCH  that  a  prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably  expect  the absence of immediate medical attention to result
in (1) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition  placing  the
health of such person or others in serious jeopardy; (2) serious impair-
ment  to  such person's bodily functions; (3) serious dysfunction of any
bodily organ or part of such person; [or] (4) serious  disfigurement  of
such  person;  OR (5) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III)
OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  S 52. Subsection (g-7) of section 4900 of the insurance law, as  added
by chapter 237 of the laws of 2009, is amended to read as follows:
  (g-7) "Rare disease" means a [life threatening or disabling] condition
or  disease  that  (1)(A) is currently or has been subject to a research
study by the  National  Institutes  of  Health  Rare  Diseases  Clinical
Research  Network; or (B) affects fewer than two hundred thousand United
States residents per year; and (2) for which  there  does  not  exist  a
standard  health  service  or  procedure covered by the health care plan
that is more clinically beneficial than the requested health service  or
treatment.  A  physician,  other  than the insured's treating physician,
shall certify in writing that the condition is a rare disease as defined
in this subsection. The certifying physician shall be a licensed, board-
certified or board-eligible physician who specializes  in  the  area  of
practice  appropriate  to  treat the insured's rare disease. The certif-
ication shall provide either: (1) that the  insured's  rare  disease  is
currently or has been subject to a research study by the National Insti-
tutes of Health Rare Diseases Clinical Research Network; or (2) that the
insured's  rare  disease  affects fewer than two hundred thousand United
States residents per year. The certification shall rely on  medical  and
scientific  evidence  to  support the requested health service or proce-
dure, if such evidence exists, and shall include a statement that, based
on the physician's credible experience, there is no  standard  treatment
that  is likely to be more clinically beneficial to the insured than the
requested health service or procedure and the requested  health  service
or  procedure  is  likely to benefit the insured in the treatment of the
insured's rare disease and that such benefit to  the  insured  outweighs
the  risks of such health service or procedure. The certifying physician
shall disclose any material financial or professional relationship  with
the provider of the requested health service or procedure as part of the
application  for  external appeal of denial of a rare disease treatment.
If the provision of the requested  health  service  or  procedure  at  a
health  care facility requires prior approval of an institutional review
board, an insured or insured's designee shall also submit such  approval
as part of the external appeal application.
  S  53.  Subparagraphs  (A) and (B) of paragraph 1 of subsection (b) of
section 4910 of the insurance law, as added by chapter 586 of  the  laws
of 1998, are amended to read as follows:
  (A)  the  insured  has  had coverage of the health care service, which
would otherwise be a covered benefit  under  a  subscriber  contract  or
governmental  health  benefit  program, denied on appeal, in whole or in
part, pursuant to title one of this article on  the  grounds  that  such
health  care  service  [is  not  medically  necessary] DOES NOT MEET THE
HEALTH CARE PLAN'S REQUIREMENTS FOR MEDICAL NECESSITY,  APPROPRIATENESS,

S. 5800                            36

HEALTH  CARE SETTING, LEVEL OF CARE, OR EFFECTIVENESS OF A COVERED BENE-
FIT, and
  (B)  the  health  care plan has rendered a final adverse determination
with respect to such health care  service  or  both  the  plan  and  the
insured have jointly agreed to waive any internal appeal, OR THE INSURED
IS  DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL
APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC  HEALTH  SERVICE  ACT,  42
U.S.C. S 300GG-19; or
  S  54. Subparagraphs (A), (B) and (C) of paragraph 2 of subsection (b)
of section 4910 of the insurance law, subparagraph (A) as added by chap-
ter 586 of the laws of 1998, and subparagraphs (B) and (C) as amended by
chapter 237 of the laws of 2009, are amended to read as follows:
  (A) the insured has had coverage of a health care  service  denied  on
the basis that such service is experimental or investigational, and such
denial  has  been  upheld  on  appeal  under [section four thousand nine
hundred four] TITLE ONE of this  article,  or  both  the  plan  and  the
insured have jointly agreed to waive any internal appeal, OR THE INSURED
IS  DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL
APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC  HEALTH  SERVICE  ACT,  42
U.S.C. S 300GG-19, and
  (B)  the  insured's attending physician has certified that the insured
has a [life-threatening or disabling] condition or disease (a) for which
standard health services or procedures have been ineffective or would be
medically inappropriate, or (b) for which there does not  exist  a  more
beneficial  standard  health  service or procedure covered by the health
care plan, or (c) for which  there  exists  a  clinical  trial  or  rare
disease treatment, and
  (C)  the insured's attending physician, who must be a licensed, board-
certified or board-eligible physician qualified to practice in the  area
of  practice  appropriate  to  treat  the insured's [life-threatening or
disabling] condition or disease, must  have  recommended  either  (a)  a
health  service  or procedure (including a pharmaceutical product within
the meaning of subparagraph (B) of paragraph two of  subsection  (e)  of
section  four  thousand nine hundred of this article) that, based on two
documents from the available medical and scientific evidence, is  likely
to  be  more  beneficial to the insured than any covered standard health
service or procedure or, in the case of a rare  disease,  based  on  the
physician's  certification  required by subsection (g-7) of section four
thousand nine hundred of this article and such  other  evidence  as  the
insured, the insured's designee or the insured's attending physician may
present,  that  the  requested  health service or procedure is likely to
benefit the insured in the treatment of the insured's rare  disease  and
that  such  benefit  to  the  insured outweighs the risks of such health
service or procedure; or (b) a clinical trial for which the  insured  is
eligible.  Any physician certification provided under this section shall
include a statement of the evidence relied  upon  by  the  physician  in
certifying his or her recommendation, and
  S 55. Subsection (c) of section 4910 of the insurance law, as added by
chapter 586 of the laws of 1998, is amended to read as follows:
  (c)  (1)  The  health  care plan may charge the insured a fee of up to
[fifty] TWENTY-FIVE dollars per external appeal WITH AN ANNUAL LIMIT  ON
FILING  FEES  FOR AN INSURED NOT TO EXCEED SEVENTY-FIVE DOLLARS WITHIN A
SINGLE PLAN YEAR; provided that, in the event the external appeal  agent
overturns the final adverse determination of the plan, such fee shall be
refunded  to the insured. Notwithstanding the foregoing, the health plan
shall not require the enrollee to pay any such fee if the enrollee is  a

S. 5800                            37

recipient  of  medical  assistance or is covered by a policy pursuant to
title one-A of article twenty-five of the public health law.    Notwith-
standing the foregoing, the health plan shall not require the insured to
pay  any  such  fee  if such fee shall pose a hardship to the [enrollee]
INSURED as determined by the plan.
  (2) THE HEALTH CARE PLAN MAY CHARGE THE INSURED'S HEALTH CARE PROVIDER
A FEE OF UP TO FIFTY DOLLARS PER EXTERNAL  APPEAL,  OTHER  THAN  FOR  AN
EXTERNAL  APPEAL  REQUESTED  PURSUANT  TO  PARAGRAPH  TWO  OR  THREE  OF
SUBSECTION (D) OF SECTION FOUR THOUSAND NINE HUNDRED  FOURTEEN  OF  THIS
ARTICLE; PROVIDED THAT, IN THE EVENT THE EXTERNAL APPEAL AGENT OVERTURNS
THE  FINAL ADVERSE DETERMINATION OF THE PLAN, SUCH FEE SHALL BE REFUNDED
TO THE INSURED'S HEALTH CARE PROVIDER.
  S 56. Paragraphs 4 and 5 of subsection (b)  of  section  4912  of  the
insurance  law, as added by chapter 586 of the laws of 1998, are amended
and a new paragraph 6 is added to read as follows:
  (4) establish a toll-free telephone service to receive information  on
a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
to  this  title. Such system shall be capable of accepting, recording or
providing instruction to incoming  telephone  calls  during  other  than
normal business hours[, and];
  (5) develop procedures to ensure that:
  (i)  appropriate  personnel  are  reasonably  accessible not less than
forty hours per week during normal business  hours  to  discuss  patient
care and to allow response to telephone requests, and
  (ii)  response to accepted or recorded messages shall be made not less
than one business day after the date on which the call was  received[.];
AND
  (6)  BE  ACCREDITED  BY  A  NATIONALLY  RECOGNIZED PRIVATE ACCREDITING
ORGANIZATION.
  S 57. Paragraphs 1 and 3 of subsection (b)  of  section  4914  of  the
insurance  law,  paragraph 1 as added by chapter 586 of the laws of 1998
and paragraph 3 as amended by chapter 237  of  the  laws  of  2009,  are
amended to read as follows:
  (1)  The  insured shall have [forty-five days] FOUR MONTHS to initiate
an external appeal after the insured receives  notice  from  the  health
care  plan,  or such plan's utilization review agent if applicable, of a
final adverse determination or denial, or after both the  plan  and  the
[enrollee]  INSURED have jointly agreed to waive any internal appeal, OR
AFTER THE INSURED IS DEEMED TO HAVE EXHAUSTED  OR  IS  NOT  REQUIRED  TO
COMPLETE  ANY  INTERNAL  APPEAL  PURSUANT  TO SECTION 2719 OF THE PUBLIC
HEALTH  SERVICE  ACT,  42  U.S.C.  S  300GG-19.  WHERE  APPLICABLE,  THE
INSURED'S HEALTH CARE PROVIDER SHALL HAVE FORTY-FIVE DAYS TO INITIATE AN
EXTERNAL APPEAL AFTER THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER,
AS APPLICABLE, RECEIVES NOTICE FROM THE HEALTH CARE PLAN, OR SUCH PLAN'S
UTILIZATION REVIEW AGENT IF APPLICABLE, OF A FINAL ADVERSE DETERMINATION
OR  DENIAL OR AFTER BOTH THE PLAN AND THE INSURED HAVE JOINTLY AGREED TO
WAIVE ANY INTERNAL APPEAL. Such request shall be in writing  in  accord-
ance with the instructions and in such form prescribed by subsection (e)
of  this  section.  The  insured, and the insured's health care provider
where applicable,  shall  have  the  opportunity  to  submit  additional
documentation  with  respect to such appeal to the external appeal agent
within [such forty-five-day period] THE APPLICABLE  TIME  PERIOD  ABOVE;
provided  however  that  when  such  documentation represents a material
change from the documentation upon which the  utilization  review  agent
based  its adverse determination or upon which the health plan based its

S. 5800                            38

denial, the health plan shall have three business days to consider  such
documentation and amend or confirm such adverse determination.
  (3)  Notwithstanding  the provisions of paragraphs one and two of this
subsection, if the insured's attending physician states that a delay  in
providing  the  health  care  service  would pose an imminent or serious
threat to the health of the insured, OR IF THE INSURED IS ENTITLED TO AN
EXPEDITED EXTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC  HEALTH
SERVICE  ACT,  42  U.S.C.    S  300GG-19,  the  external appeal shall be
completed within [three days] NO MORE  THAN  SEVENTY-TWO  HOURS  of  the
request  therefor and the external appeal agent shall make every reason-
able attempt to immediately notify the  insured,  the  insured's  health
care  provider  where  appropriate,  and the health plan of its determi-
nation by  telephone  or  facsimile,  followed  immediately  by  written
notification of such determination.
  S  58.  Clause  (a) of item (ii) of subparagraph (B) of paragraph 4 of
subsection (b) of section 4914 of the insurance law, as amended by chap-
ter 237 of the laws of 2009, is amended to read as follows:
  (a) that the patient costs of the proposed health service or procedure
shall be covered by the health care plan either: when a majority of  the
panel  of  reviewers  determines,  based  upon  review of the applicable
medical and scientific evidence and, in connection with  rare  diseases,
the  physician's  certification  required by subsection (g-7) of section
four thousand nine hundred of this article and such  other  evidence  as
the insured, the insured's designee or the insured's attending physician
may  present  (or  upon confirmation that the recommended treatment is a
clinical trial), the insured's medical record, and any  other  pertinent
information,  that the proposed health service or treatment (including a
pharmaceutical product within the meaning of subparagraph (B)  of  para-
graph  two  of  subsection  (e) of section four thousand nine hundred of
this article) is likely to be more beneficial than any  standard  treat-
ment  or  treatments  for  the insured's [life-threatening or disabling]
condition or disease or, for rare diseases, that  the  requested  health
service  or  procedure is likely to benefit the insured in the treatment
of the insured's rare disease and  that  such  benefit  to  the  insured
outweighs the risks of such health service or procedure (or, in the case
of  a  clinical trial, is likely to benefit the insured in the treatment
of the insured's condition or disease); or when  a  reviewing  panel  is
evenly  divided  as to a determination concerning coverage of the health
service or procedure, or
  S 59. Section 4403 of the public health law is amended by adding a new
subdivision 7 to read as follows:
  7. A HEALTH MAINTENANCE ORGANIZATION THAT  REQUIRES  OR  PROVIDES  FOR
DESIGNATION  BY  AN  ENROLLEE  OF  A PARTICIPATING PRIMARY CARE PROVIDER
SHALL PERMIT THE ENROLLEE TO DESIGNATE ANY  PARTICIPATING  PRIMARY  CARE
PROVIDER  WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL, AND IN THE CASE OF
A CHILD, SHALL PERMIT THE ENROLLEE TO DESIGNATE A PHYSICIAN  (ALLOPATHIC
OR  OSTEOPATHIC)  WHO  SPECIALIZES  IN PEDIATRICS AS THE CHILD'S PRIMARY
CARE PROVIDER IF SUCH PROVIDER PARTICIPATES IN THE NETWORK OF THE HEALTH
MAINTENANCE ORGANIZATION.
  S 60. Subdivisions 1 and 2 of section 4406-b of the public health law,
as added by chapter 645 of the laws of 1994,  are  amended  to  read  as
follows:
  1.  The  health  maintenance  organization  shall  not  limit a female
enrollee's direct access to primary and preventive obstetric and gyneco-
logic services, INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM  SUCH
ANNUAL EXAMINATIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from

S. 5800                            39

a qualified provider of such services of her choice from within the plan
[to  less  than two examinations annually for such services] or [to] FOR
any care related to a pregnancy[. In addition,  the  health  maintenance
organization  shall  not  limit  direct access to primary and preventive
obstetric and gynecologic services required as a result of  such  annual
examinations or as a result of an acute gynecologic condition], provided
that:  (A) such qualified provider discusses such services and treatment
plan with the enrollee's primary care practitioner  in  accordance  with
the  requirements  of  the health maintenance organization; AND (B) SUCH
QUALIFIED PROVIDER AGREES TO ADHERE TO THE HEALTH MAINTENANCE  ORGANIZA-
TION'S  POLICIES  AND  PROCEDURES,  INCLUDING  ANY APPLICABLE PROCEDURES
REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR SERVICES OTHER
THAN OBSTETRIC AND  GYNECOLOGIC  SERVICES  RENDERED  BY  SUCH  QUALIFIED
PROVIDER,  AND  AGREES  TO PROVIDE SERVICES PURSUANT TO A TREATMENT PLAN
(IF ANY) APPROVED BY THE HEALTH MAINTENANCE ORGANIZATION.
  2. A HEALTH MAINTENANCE ORGANIZATION  SHALL  TREAT  THE  PROVISION  OF
OBSTETRIC  AND  GYNECOLOGIC  CARE, AND THE ORDERING OF RELATED OBSTETRIC
AND GYNECOLOGIC ITEMS  AND  SERVICES,  PURSUANT  TO  THE  DIRECT  ACCESS
DESCRIBED  IN  SUBDIVISION ONE OF THIS SECTION BY A PARTICIPATING QUALI-
FIED PROVIDER OF SUCH SERVICES, AS THE AUTHORIZATION OF THE PRIMARY CARE
PROVIDER.
  3. It shall be the duty of the administrative officer or other  person
in  charge of each health maintenance organization to advise each female
enrollee, in writing, of the provisions of this section.
  S 61. Subdivision 3 of section 4900 of the public health law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
  3. "Emergency condition" means a medical or behavioral condition, [the
onset of which is sudden,] that manifests itself by  ACUTE  symptoms  of
sufficient  severity, including severe pain, SUCH that a prudent layper-
son, possessing an average  knowledge  of  medicine  and  health,  could
reasonably  expect  the absence of immediate medical attention to result
in (a) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition, placing  the
health of such person or others in serious jeopardy; (b) serious impair-
ment  to  such person's bodily functions; (c) serious dysfunction of any
bodily organ or part of such person; [or] (d) serious  disfigurement  of
such  person;  OR (E) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III)
OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT.
  S 62. Subdivision 7-g of section 4900 of the  public  health  law,  as
added by chapter 237 of the laws of 2009, is amended to read as follows:
  7-g.  "Rare disease" means a [life threatening or disabling] condition
or disease that (1)(A) is currently or has been subject  to  a  research
study  by  the  National  Institutes  of  Health  Rare Diseases Clinical
Research Network or (B) affects fewer than two hundred  thousand  United
States  residents  per  year,  and  (2) for which there does not exist a
standard health service or procedure covered by  the  health  care  plan
that  is more clinically beneficial than the requested health service or
treatment. A physician, other than the  enrollee's  treating  physician,
shall certify in writing that the condition is a rare disease as defined
in this subsection. The certifying physician shall be a licensed, board-
certified  or  board-eligible  physician  who specializes in the area of
practice appropriate to treat the enrollee's rare disease.  The  certif-
ication  shall  provide  either:  (1) that the insured's rare disease is
currently or has been subject to a research study by the National Insti-
tutes of Health Rare Diseases Clinical Research Network; or (2) that the
insured's rare disease affects fewer than two  hundred  thousand  United

S. 5800                            40

States  residents  per year. The certification shall rely on medical and
scientific evidence to support the requested health  service  or  proce-
dure, if such evidence exists, and shall include a statement that, based
on  the  physician's credible experience, there is no standard treatment
that is likely to be more clinically beneficial to the enrollee than the
requested health service or procedure and the requested  health  service
or  procedure  is likely to benefit the enrollee in the treatment of the
enrollee's rare disease and that such benefit to the enrollee  outweighs
the risks of such health service or procedure.  The certifying physician
shall  disclose any material financial or professional relationship with
the provider of the requested health service or procedure as part of the
application for external appeal of denial of a rare  disease  treatment.
If  the  provision  of  the  requested  health service or procedure at a
health care facility requires prior approval of an institutional  review
board,  an  enrollee  or  enrollee's  designee  shall  also  submit such
approval as part of the external appeal application.
  S 63. Subparagraphs (i) and (ii) of paragraph (a) of subdivision 2  of
section  4910  of  the public health law, as added by chapter 586 of the
laws of 1998, are amended to read as follows:
  (i) the enrollee has had coverage of  a  health  care  service,  which
would  otherwise  be  a  covered  benefit under a subscriber contract or
governmental health benefit program, denied on appeal, in  whole  or  in
part,  pursuant  to  title  one of this article on the grounds that such
health care service [is not  medically  necessary]  DOES  NOT  MEET  THE
HEALTH  CARE PLAN'S REQUIREMENTS FOR MEDICAL NECESSITY, APPROPRIATENESS,
HEALTH CARE SETTING, LEVEL OF CARE, OR EFFECTIVENESS OF A COVERED  BENE-
FIT, and
  (ii)  the  health care plan has rendered a final adverse determination
with respect to such health care service or both the plan and the enrol-
lee have jointly agreed to waive any internal appeal, OR THE ENROLLEE IS
DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED  TO  COMPLETE  ANY  INTERNAL
APPEAL  PURSUANT  TO  SECTION  2719 OF THE PUBLIC HEALTH SERVICE ACT, 42
U.S.C. S 300GG-19; or
  S 64. Subparagraphs (i), (ii) and (iii) of paragraph (b)  of  subdivi-
sion  2  of  section  4910 of the public health law, subparagraph (i) as
added by chapter 586 of the laws of 1998,  and  subparagraphs  (ii)  and
(iii) as amended by chapter 237 of the laws of 2009, are amended to read
as follows:
  (i)  the  enrollee has had coverage of a health care service denied on
the basis that such service is experimental or investigational, and such
denial has been upheld on appeal under title one  of  this  article,  or
both the plan and the enrollee have jointly agreed to waive any internal
appeal,  OR  THE ENROLLEE IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED
TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE  FEDERAL
PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19, and
  (ii)  the enrollee's attending physician has certified that the enrol-
lee has a [life-threatening or disabling] condition or disease  (a)  for
which  standard  health  services or procedures have been ineffective or
would be medically inappropriate, or (b) for which there does not  exist
a  more  beneficial  standard health service or procedure covered by the
health care plan, or (c) for which there exists a clinical trial or rare
disease treatment, and
  (iii) the enrollee's attending physician,  who  must  be  a  licensed,
board-certified or board-eligible physician qualified to practice in the
area  of  practice appropriate to treat the enrollee's [life threatening
or disabling] condition or disease, must have recommended either  (a)  a

S. 5800                            41

health  service  or procedure (including a pharmaceutical product within
the meaning of subparagraph (B) of paragraph (b) of subdivision five  of
section forty-nine hundred of this article) that, based on two documents
from the available medical and scientific evidence, is likely to be more
beneficial  to  the enrollee than any covered standard health service or
procedure or, in the case of a rare disease, based  on  the  physician's
certification  required  by  subdivision  seven-g  of section forty-nine
hundred of this article and such other evidence  as  the  enrollee,  the
enrollee's  designee  or the enrollee's attending physician may present,
that the requested health service or procedure is likely to benefit  the
enrollee  in  the treatment of the enrollee's rare disease and that such
benefit to the enrollee outweighs the risks of such  health  service  or
procedure;  or  (b) a clinical trial for which the enrollee is eligible.
Any physician certification provided under this section shall include  a
statement of the evidence relied upon by the physician in certifying his
or her recommendation, and
  S 65. Subdivision 3 of section 4910 of the public health law, as added
by chapter 586 of the laws of 1998, is amended to read as follows:
  3.  (A)  The  health  care plan may charge the enrollee a fee of up to
[fifty] TWENTY-FIVE dollars per external appeal WITH AN ANNUAL LIMIT  ON
FILING  FEES FOR AN ENROLLEE NOT TO EXCEED SEVENTY-FIVE DOLLARS WITHIN A
SINGLE PLAN YEAR; provided that, in the event the external appeal  agent
overturns the final adverse determination of the plan, such fee shall be
refunded to the enrollee. Notwithstanding the foregoing, the health plan
shall  not require the enrollee to pay any such fee if the enrollee is a
recipient of medical assistance or is covered by a  policy  pursuant  to
title one-A of article twenty-five of this chapter.  Notwithstanding the
foregoing,  the  health  plan  shall not require the enrollee to pay any
such fee if such fee shall pose a hardship to the enrollee as determined
by the plan.
  (B) THE HEALTH CARE PLAN MAY CHARGE THE ENROLLEE'S HEALTH CARE PROVID-
ER A FEE OF UP TO FIFTY DOLLARS PER EXTERNAL APPEAL, OTHER THAN  FOR  AN
EXTERNAL  APPEAL  REQUESTED PURSUANT TO PARAGRAPH (B) OR (C) OF SUBDIVI-
SION FOUR OF  SECTION  FORTY-NINE  HUNDRED  FOURTEEN  OF  THIS  ARTICLE;
PROVIDED  THAT,  IN  THE  EVENT  THE EXTERNAL APPEAL AGENT OVERTURNS THE
FINAL ADVERSE DETERMINATION OF THE PLAN, SUCH FEE SHALL BE  REFUNDED  TO
THE ENROLLEE'S HEALTH CARE PROVIDER.
  S  66.  Paragraphs (d) and (e) of subdivision 2 of section 4912 of the
public health law, as added by chapter 586 of  the  laws  of  1998,  are
amended and a new paragraph (f) is added to read as follows:
  (d)  establish a toll-free telephone service to receive information on
a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
to this title. Such system shall be capable of accepting,  recording  or
providing  instruction  to  incoming  telephone  calls during other than
normal business hours[, and];
  (e) develop procedures to ensure that:
  (i) appropriate personnel are  reasonably  accessible  not  less  than
forty  hours  per  week  during normal business hours to discuss patient
care and to allow response to telephone requests, and
  (ii) response to accepted or recorded messages shall be made not  less
than  one business day after the date on which the call was received[.];
AND
  (F) BE ACCREDITED  BY  A  NATIONALLY  RECOGNIZED  PRIVATE  ACCREDITING
ORGANIZATION.
  S  67.  Paragraphs (a) and (c) of subdivision 2 of section 4914 of the
public health law, paragraph (a) as added by chapter 586 of the laws  of

S. 5800                            42

1998  and  paragraph  (c) as amended by chapter 237 of the laws of 2009,
are amended to read as follows:
  (a)  The enrollee shall have [forty-five days] FOUR MONTHS to initiate
an external appeal after the enrollee receives notice  from  the  health
care  plan,  or such plan's utilization review agent if applicable, of a
final adverse determination or denial or after both  the  plan  and  the
enrollee  have jointly agreed to waive any internal appeal, OR AFTER THE
ENROLLEE IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE  ANY
INTERNAL  APPEAL  PURSUANT  TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE
ACT, 42 U.S.C. S 300GG-19. WHERE APPLICABLE, THE ENROLLEE'S HEALTH  CARE
PROVIDER SHALL HAVE FORTY-FIVE DAYS TO INITIATE AN EXTERNAL APPEAL AFTER
THE  ENROLLEE  OR  THE  ENROLLEE'S  HEALTH CARE PROVIDER, AS APPLICABLE,
RECEIVES NOTICE FROM THE HEALTH CARE PLAN, OR  SUCH  PLAN'S  UTILIZATION
REVIEW  AGENT  IF APPLICABLE, OF A FINAL ADVERSE DETERMINATION OR DENIAL
OR AFTER BOTH THE PLAN AND THE ENROLLEE HAVE JOINTLY AGREED TO WAIVE ANY
INTERNAL APPEAL. Such request shall be in writing in accordance with the
instructions and in such form prescribed by  subdivision  five  of  this
section.  The  enrollee,  and  the enrollee's health care provider where
applicable, shall have the opportunity to submit  additional  documenta-
tion  with  respect  to  such appeal to the external appeal agent within
[such forty-five-day period] THE APPLICABLE TIME PERIOD ABOVE;  provided
however  that  when such documentation represents a material change from
the documentation upon which the  utilization  review  agent  based  its
adverse  determination  or  upon which the health plan based its denial,
the health plan shall have three business days to consider such documen-
tation and amend or confirm such adverse determination.
  (c) Notwithstanding the provisions of paragraphs (a) and (b)  of  this
subdivision,  if  the enrollee's attending physician states that a delay
in providing the health care service would pose an imminent  or  serious
threat  to the health of the enrollee, OR IF THE ENROLLEE IS ENTITLED TO
AN EXPEDITED EXTERNAL APPEAL PURSUANT TO SECTION  2719  OF  THE  FEDERAL
PUBLIC  HEALTH  SERVICE  ACT,  42 U.S.C. S 300GG-19, the external appeal
shall be completed within [three days] NO MORE THAN SEVENTY-TWO HOURS of
the request therefor and the external  appeal  agent  shall  make  every
reasonable  attempt  to  immediately notify the enrollee, the enrollee's
health care provider where appropriate,  and  the  health  plan  of  its
determination by telephone or facsimile, followed immediately by written
notification of such determination.
  S  68.  Item  1 of clause (ii) of subparagraph (B) of paragraph (d) of
subdivision 2 of section 4914 of the public health law,  as  amended  by
chapter 237 of the laws of 2009, is amended to read as follows:
  (1) that the patient costs of the proposed health service or procedure
shall  be covered by the health care plan either: when a majority of the
panel of reviewers determines,  based  upon  review  of  the  applicable
medical  and  scientific evidence and, in connection with rare diseases,
the physician's certification required by subdivision seven-g of section
forty-nine hundred of this article and such other evidence as the enrol-
lee, the enrollee's designee or the enrollee's attending  physician  may
present  (or upon confirmation that the recommended treatment is a clin-
ical trial), the enrollee's medical  record,  and  any  other  pertinent
information,  that the proposed health service or treatment (including a
pharmaceutical product within the meaning of subparagraph (B)  of  para-
graph  (b)  of  subdivision  five  of section forty-nine hundred of this
article) is likely to be more beneficial than any standard treatment  or
treatments  for the enrollee's [life-threatening or disabling] condition
or disease or, for rare diseases, that the requested health  service  or

S. 5800                            43

procedure  is  likely  to  benefit  the enrollee in the treatment of the
enrollee's rare disease and that such benefit to the enrollee  outweighs
the  risks  of  such  health  service or procedure (or, in the case of a
clinical  trial,  is  likely to benefit the enrollee in the treatment of
the enrollee's condition or disease); or when a reviewing panel is even-
ly divided as to a  determination  concerning  coverage  of  the  health
service or procedure, or
  S 69. If any provision of this act or the application thereof shall be
held to be invalid, such invalidity shall not affect other provisions of
this act which can be given effect without the invalid provision; and to
that end, the provisions of this act are severable.
  S 70. This act shall take effect immediately:
  1.  provided,  that  for  policies  renewed  on or after such date but
before September 23, 2011, this act shall take effect upon  the  renewal
date;
  2.  provided,  however,  that  sections  eight,  nine,  ten, fourteen,
fifteen, sixteen, seventeen, eighteen, twenty-three,  twenty-six,  twen-
ty-seven, twenty-eight, twenty-nine, thirty, forty, forty-one, forty-two
and  forty-three  of this act shall, with respect to blanket policies of
hospital, medical,  surgical  or  prescription  drug  expense  insurance
covering  students  pursuant  to  subparagraph  (C)  of  paragraph  3 of
subsection (a) of section 4237 of the insurance law, take effect January
1, 2012 and apply to policies issued or renewed on and after such  date;
and
  3.  provided,  further,  that  sections fifty-two, fifty-three, fifty-
four,  fifty-five,  fifty-six,  fifty-seven,   fifty-eight,   sixty-two,
sixty-three,  sixty-four,  sixty-five, sixty-six, sixty-seven and sixty-
eight of this act shall take effect on the later of July 1, 2011, or the
date the external appeal requirements of  section  2719  of  the  Public
Health  Service Act, 42 U.S.C. S 300gg-19 are determined to be effective
by the Secretary of Health and Human  Services  and  apply  to  a  final
adverse determination issued on and after such date.

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