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.