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SECTION 3221
Group or blanket accident and health insurance policies; standard provisions
Insurance (ISC) CHAPTER 28, ARTICLE 32
§ 3221. Group or blanket accident and health insurance policies;
standard provisions. (a) No policy of group or blanket accident and
health insurance shall, except as provided in subsection (d) hereof, be
delivered or issued for delivery in this state unless it contains in
substance the following provisions or provisions which in the opinion of
the superintendent are more favorable to the holders of such
certificates or not less favorable to the holders of such certificates
and more favorable to policyholders, provided however, that the
provisions set forth in paragraphs six and thirteen of this subsection
shall not be applicable to any such policy which is issued to a
policyholder in accordance with subparagraph (E) of paragraph one of
subsection (c) of section four thousand two hundred thirty-five of this
chapter:

(1) (A) No statement made by the person insured shall avoid the
insurance or reduce benefits thereunder unless contained in a written
instrument signed by the person insured.

(B) All statements contained in any such written instrument shall be
deemed representations and not warranties.

(2) That no agent has authority to change the policy or waive any of
its provisions and that no change in the policy shall be valid unless
approved by an officer of the insurer and evidenced by endorsement on
the policy, or by amendment to the policy signed by the policyholder and
the insurer.

(3) That all new employees or new members in the classes eligible for
insurance must be added to such class for which they are eligible.

(4) That all premiums due under the policy shall be remitted by the
employer or employers of the persons insured or by some other designated
person acting on behalf of the association or group insured, to the
insurer on or before the due date thereof, with such period of grace as
may be specified therein.

(5) The conditions under which the insurer may decline to renew the
policy.

(6) That the insurer shall issue either to the employer or person in
whose name such policy is issued, for delivery to each member of the
insured group, a certificate setting forth in summary form a statement
of the essential features of the insurance coverage and in substance the
following provisions of this subsection.

(7) The ages, to which the insurance provided therein shall be
limited; and the ages, for which additional restrictions are placed on
benefits, and the additional restrictions placed on the benefits at such
ages.

(8) That written notice of claim must be given to the insurer within
twenty days after the occurrence or commencement of any loss covered by
the policy. Failure to give notice within such time shall not invalidate
or reduce any claim if it shall be shown not to have been reasonably
possible to give such notice and that notice was given as soon as was
reasonably possible.

(9) That in the case of claim for loss of time for disability, written
proof of such loss must be furnished to the insurer within thirty days
after the commencement of the period for which the insurer is liable,
and that subsequent written proofs of the continuance of such disability
must be furnished to the insurer at such intervals as the insurer may
reasonably require, and that in the case of claim for any other loss,
written proof of such loss must be furnished to the insurer within one
hundred twenty days after the date of such loss. Failure to furnish such
proof within such time shall not invalidate or reduce any claim if it
shall be shown not to have been reasonably possible to furnish such
proof within such time, provided such proof was furnished as soon as
reasonably possible.

(10) That the insurer will furnish to the person making claim or to
the policyholder for delivery to such person such forms as are usually
furnished by it for filing proof of loss. If such forms are not
furnished before the expiration of fifteen days after the insurer
receives notice of any claim under the policy, the person making such
claim shall be deemed to have complied with the requirements of the
policy as to proof of loss upon submitting within the time fixed in the
policy for filing proof of loss, written proof covering the occurrence,
character and extent of the loss for which claim is made.

(11) That the insurer shall have the right and opportunity to examine
the person of the individual for whom claim is made when and so often as
it may reasonably require during the pendency of claim under the policy
and also the right and opportunity to make an autopsy in case of death
where it is not prohibited by law.

(12) That benefits payable under the policy other than benefits for
loss of time will be payable not more than sixty days after receipt of
proof, and that, subject to due proof of loss all accrued benefits
payable under the policy for loss of time will be paid not less
frequently than monthly during the continuance of the period for which
the insurer is liable, and that any balance remaining unpaid at the
termination of such period will be paid immediately upon receipt of such
proof.

(13) That indemnity for loss of life of the insured is payable in
accordance with subsection (e) of section four thousand two hundred
thirty-five of this chapter; and that all other indemnities of the
policy are payable to the insured, except as may be otherwise provided
in accordance with such subsection; and that if a beneficiary is
designated, the consent of the beneficiary shall not be requisite to
change of beneficiary, or to any other changes in the policy or
certificate, except as may be specifically provided by the policy.

(14) That no action at law or in equity shall be brought to recover on
the policy prior to the expiration of sixty days after proof of loss has
been filed in accordance with the requirements of the policy and that no
such action shall be brought after the expiration of two years following
the time such proof of loss is required by the policy.

(15) Any policy and certificate, other than one issued in fulfillment
of the continuing care responsibilities of an operator of a continuing
care retirement community in accordance with article forty-six of the
public health law, made available because of residence in a particular
facility, housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:

"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF
A CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE
WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT
COMMUNITY."

(16) No policy delivered or issued for delivery in this state which
provides coverage for prescription drugs and for which cost-sharing,
deductibles or co-insurance obligations are determined by category of
prescription drugs shall impose cost-sharing, deductibles or
co-insurance obligations for any prescription drug that exceeds the
dollar amount of cost-sharing, deductibles or co-insurance obligations
for non-preferred brand drugs or its equivalent (or brand drugs if there
is no non-preferred brand drug category).

(b) No such policy shall be delivered or issued for delivery in this
state unless a schedule of the premium rates pertaining to such form
shall have been filed with the superintendent.

(c) Any portion of any such policy, which purports, by reason of the
circumstances under which a loss is incurred, to reduce any benefits
promised thereunder to an amount less than that provided for the same
loss occurring under ordinary circumstances, shall be printed, in such
policy and in each certificate issued thereunder, in bold face type and
with greater prominence than any other portion of the text of such
policy or certificate; and all other exceptions of the policy shall be
printed in the policy and in the certificate, with the same prominence
as the benefits to which they apply. If any such policy contains any
provision which affects the liability of the insurer, on the grounds
stated in subparagraph (J) or (K) of paragraph two of subsection (d) of
section three thousand two hundred sixteen of this article, then such
provision shall be contained in the policy and certificate in the form
set forth in such section.

(d) (1) The superintendent may approve any form of certificate to be
issued under a blanket accident and health insurance policy as defined
in section four thousand two hundred thirty-seven of this chapter, which
omits or modifies any of the provisions hereinbefore required, if the
superintendent deems such omission or modification suitable for the
character of such insurance and not unjust to the persons insured
thereunder. Certificates issued under a policy or contract of student
accident and health insurance as defined in section three thousand two
hundred forty of this article shall comply with such section.

(2) The superintendent may approve any form of group insurance policy
providing disability benefits to be issued pursuant to article nine of
the workers' compensation law which omits or modifies any of the
provisions hereinbefore required, if such omission or modification is
not inconsistent with the provisions of such article nine and he deems
such omission or modification suitable for the character of such
insurance and not unjust to the persons insured thereunder.

(3) The superintendent may also approve any form of group insurance
policy to be issued to a social services district pursuant to
subdivision two of section three hundred sixty-seven-a of the social
services law, which omits or modifies any of the provisions hereinbefore
required, if he deems such omission or modification suitable for the
character of such insurance.

(e) (1) A group policy providing hospital, medical or surgical expense
insurance for other than specific diseases or accident only, shall
provide that if the insurance on an employee or member insured under the
group policy ceases because of termination of (A) employment or of
membership in the class or classes eligible for coverage under the
policy or (B) the policy, for any reason whatsoever, unless the
policyholder has replaced the group policy with similar and continuous
coverage for the same group whether insured or self-insured, such
employee or member who has been insured under the group policy shall be
entitled to have issued to the insured by the insurer without evidence
of insurability upon application made to the insurer within sixty days
after such termination, and payment of the quarterly, or, at the option
of the employee or member, a less frequent premium applicable to the
form and amount of insurance, an individual policy of insurance. The
insurer may, at its option elect to provide the insurance coverage under
a group insurance policy, delivered in this state, in lieu of the
issuance of a converted individual policy of insurance. Such individual
policy, or group policy, as the case may be is hereafter referred to as
the converted policy. The benefits provided under the converted policy
shall be those required by subsection (f) and (g) of this section, in
the event of termination of the converted group policy of insurance,
each insured thereunder shall have a right of conversion to a converted
individual policy of insurance.

(2) The insurer shall not be required to issue a converted policy
covering any person if such person is covered for similar benefits by
another hospital or surgical or medical expense insurance policy or
hospital or medical service subscriber contract or medical practice or
other prepayment plan or by any other plan or program or such person is
eligible for similar benefits, whether or not covered therefor, under
any arrangement of coverage for individuals in a group, other than under
the converted policy, whether on an insured or uninsured basis or
similar benefits are provided for or available to such person pursuant
to any statute; and the benefits provided or available under any of such
sources which together with the benefits provided under the converted
policy would result in overinsurance or duplication of benefits
according to standards on file with the superintendent.

(3) The converted policy shall, at the option of the employee or
member, provide identical coverage for the dependents of such employee
or member who were covered under the group policy. Provided, however,
that if the employee or member chooses the option of dependent coverage
then dependents acquired after the permitted time to convert stated in
paragraph one of this subsection shall be added to the converted family
policy in accordance with the provisions of subsection (c) of section
thirty-two hundred sixteen of this article and any regulations
promulgated or guidelines issued by the superintendent. The effective
date of the individual's coverage under the converted policy shall be
the date of the termination of the individual's insurance under the
group policy as to those persons covered under the group policy.

(4) If delivery of an individual converted policy is to be made
outside this state, it may be on such form as the insurer may then be
offering for such conversion in the jurisdiction where such delivery is
to be made.

(5) The conversion provision shall also be available upon the death of
the employee or member, to the surviving spouse with respect to such of
the spouse and children as are then covered by the group policy, and
shall be available to a child solely with respect to himself upon his
attaining the limiting age of coverage under the group policy while
covered as a dependent thereunder. It shall also be available upon the
divorce or annulment of the marriage of the employee or member, to the
former spouse of such employee or member.

(6) (A) Each certificate holder shall be given written notice of such
conversion privilege and its duration within fifteen days before or
after the date of termination of group coverage, provided that if such
notice be given more than fifteen days but less than ninety days after
the date of termination of group coverage, the time allowed for the
exercise of such privilege of conversion shall be extended for
forty-five days after the giving of such notice. If such notice be not
given within ninety days after the date of termination of group
coverage, the time allowed for the exercise of such conversion privilege
shall expire at the end of such ninety days.

(B) Written notice by the policyholder given to the certificate holder
or mailed to the certificate holder's last known address, or written
notice by the insurer be sent by first class mail to the certificate
holder at the last address furnished to the insurer by the policyholder,
shall be deemed full compliance with the provisions of this subsection
for the giving of notice.

(C) A group contract issued by an insurer may contain a provision to
the effect that notice of such conversion privilege and its duration
shall be given by the policyholder to each certificate holder upon
termination of his group coverage.

(7) In addition to the right of conversion herein, the employee or
member insured under the policy shall at his option, as an alternative
to conversion, be entitled to have his coverage continued under the
group policy in accordance with the conditions and limitations contained
in subsection (m) of this section, and have issued at the end of the
period of continuation an individual conversion policy subject to the
terms of this subsection. The effective date for the conversion policy
shall be the day following the termination of insurance under the group
policy, or if there is a continuation of coverage, on the day following
the end of the period of continuation. Notwithstanding the foregoing,
the superintendent may require conversion or continuation of insurance
under conditions as set forth in a regulation for insureds under a
policy issued in accordance with subparagraph (E) of paragraph one of
subsection (c) of section four thousand two hundred thirty-five of this
chapter.

(8) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.

(f) If the group insurance policy insures the employee or member for
hospital, medical or surgical expense insurance, or if the group
insurance policy insures the employee or member for major medical or
similar comprehensive-type coverage, then the conversion privilege shall
entitle the employee or member to obtain coverage under a converted
policy providing, at the insured's option, coverage under any one of the
plans described in subsection (g) of this section on an expense incurred
basis.

(g) For conversion purposes, an insurer shall offer to the employee or
member a policy at each level of coverage as defined in subsection (b)
of section three thousand two hundred seventeen-i of this article that
contains the essential health benefits package described in paragraph
three of subsection (e) of section three thousand two hundred
seventeen-i of this article. Provided, however, the superintendent may,
after giving due consideration to the public interest, approve a request
made by an insurer for the insurer to satisfy the requirements of this
subsection and subsections (e) and (f) of this section through the
offering of policies that comply with this subsection by another
insurer, corporation or health maintenance organization within the
insurer's holding company system, as defined in article fifteen of this
chapter.

(h) Every small group policy or association group policy delivered or
issued for delivery in this state that provides coverage for hospital,
medical or surgical expense insurance and is not a grandfathered health
plan shall provide coverage for the essential health benefits package.
For purposes of this subsection:

(1) "essential health benefits package" shall have the meaning set
forth in paragraph three of subsection (e) of section three thousand two
hundred seventeen-i of this article;

(2) "grandfathered health plan" means coverage provided by an insurer
in which an individual was enrolled on March twenty-third, two thousand
ten for as long as the coverage maintains grandfathered status in
accordance with section 1251(e) of the affordable care act, 42 U.S.C. §
18011(e);

(3) "small group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and

(4) "association group" means a group defined in subparagraphs (B),
(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section
four thousand two hundred thirty-five of this chapter, provided that:

(A) the group includes one or more individual members; or

(B) the group includes one or more member employers or other member
groups that are small groups.

(i) An insurer shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section if the
benefits must be covered pursuant to subsection (h) of this section. For
any policy issued within the health benefit exchange established by this
state, an insurer shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section.

(j) No policy of group or blanket accident and health insurance shall
be issued as excess coverage for volunteer firefighters over and above
the coverage provided for pursuant to the volunteer firefighters'
benefit law unless such excess policy provides for each of the types of
coverages set forth in subdivision one of section five of such law. Any
excess policy which does not contain such provisions shall be construed
as if such coverages were embodied therein.

(k) (1) (A) Every group policy delivered or issued for delivery in
this state which provides coverage for in-patient hospital care shall
provide coverage for home care to residents in this state, except that
this provision shall not apply to a policy which covers persons employed
in more than one state or the benefit structure of which was the subject
of collective bargaining affecting persons who are employed in more than
one state. Such home care coverage shall be included at the inception of
all new policies and, with respect to all other policies, added at any
anniversary date of the policy subject to evidence of insurability.

(B) Such coverage may be subject to an annual deductible of not more
than fifty dollars for each person covered under the policy and may be
subject to a coinsurance provision which provides for coverage of not
less than seventy-five percent of the reasonable charges for such
services.

(C) Home care means the care and treatment of a covered person who is
under the care of a physician but only if hospitalization or confinement
in a nursing facility as defined in subchapter XVIII of the federal
Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
required if home care was not provided, and the plan covering the home
health service is established and approved in writing by such physician.

(D) Home care shall be provided by an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law and shall consist of one or more of the
following:

(i) Part-time or intermittent home nursing care by or under the
supervision of a registered professional nurse (R.N.).

(ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.

(iii) Physical, occupational or speech therapy if provided by the home
health service or agency.

(iv) Medical supplies, drugs and medications prescribed by a
physician, and laboratory services by or on behalf of a certified home
health agency or licensed home care services agency to the extent such
items would have been covered under the contract if the covered person
had been hospitalized or confined in a skilled nursing facility as
defined in subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq.

(E) For the purpose of determining the benefits for home care
available to a covered person, each visit by a member of a home care
team shall be considered as one home care visit; the contract may
contain a limitation on the number of home care visits, but not less
than forty such visits in any calendar year or in any continuous period
of twelve months, for each person covered under the contract; four hours
of home health aide service shall be considered as one home care visit.

(2) (A) Every insurer issuing a group policy delivered or issued for
delivery in this state which provides coverage for in-patient hospital
care shall include coverage for preadmission tests performed in hospital
facilities prior to scheduled surgery, except that this provision shall
not apply to a policy which covers persons employed in more than one
state or the benefit structure of which was the subject of collective
bargaining affecting persons who are employed in more than one state.

(B) Such policy shall provide benefits for tests ordered by a
physician which are performed in the out-patient facilities of a
hospital as a planned preliminary to admission of the patient as an
in-patient for surgery in the same hospital, provided that:

(i) tests are necessary for and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed;

(ii) reservations for a hospital bed and for an operating room were
made prior to the performance of the tests;

(iii) the surgery actually takes place within seven days of such
presurgical tests; and

(iv) the patient is physically present at the hospital for the tests.

(3) Every group policy delivered or issued for delivery in this state
which provides coverage for in-patient surgical care shall include
coverage for a second surgical opinion by a qualified physician on the
need for surgery, except that this provision shall not apply to a policy
which covers persons employed in more than one state or the benefit
structure of which was the subject of collective bargaining affecting
persons who are employed in more than one state.

(4) (A) Every group policy delivered or issued for delivery in this
state that provides coverage for inpatient hospital care shall include
coverage for services to treat an emergency condition provided in
hospital facilities, except that this provision shall not apply to a
policy which covers persons employed in more than one state or the
benefit structure of which was the subject of collective bargaining
affecting persons who are employed in more than one state unless the
policy otherwise provides coverage for services to treat an emergency
condition provided in hospital facilities:

(i) without the need for any prior authorization determination;

(ii) regardless of whether the health care provider furnishing such
services is a participating provider with respect to such services;

(iii) if the emergency services are provided by a non-participating
provider, without imposing any administrative requirement or limitation
on coverage that is more restrictive than the requirements or
limitations that apply to emergency services received from participating
providers; and

(iv) if the emergency services are provided by a non-participating
provider, the cost-sharing requirement (expressed as a copayment or
coinsurance) shall be the same requirement that would apply if such
services were provided by a participating provider.

(B) Any requirements of section 2719A(b) of the Public Health Service
Act, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the
requirements of this paragraph with respect to coverage of emergency
services shall be applicable to every policy subject to this paragraph.

(C) In this paragraph, an "emergency condition" means a medical or
behavioral condition that manifests itself by acute symptoms of
sufficient severity, including severe pain, such that a prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to result
in (i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition placing the
health of such person or others in serious jeopardy; (ii) serious
impairment to such person's bodily functions; (iii) serious dysfunction
of any bodily organ or part of such person; (iv) serious disfigurement
of such person; or (v) a condition described in clause (i), (ii) or
(iii) of section 1867(e)(1)(A) of the Social Security Act.

(D) In this paragraph, "emergency services" means, with respect to an
emergency condition: (i) a medical screening examination as required
under section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, which
is within the capability of the emergency department of a hospital,
including ancillary services routinely available to the emergency
department to evaluate such emergency medical condition: and (ii) within
the capabilities of the staff and facilities available at the hospital,
such further medical examination and treatment as are required under
section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, to
stabilize the patient.

(E) In this paragraph, "to stabilize" means, with respect to an
emergency condition, to provide such medical treatment of the condition
as may be necessary to assure, within reasonable medical probability,
that no material deterioration of the condition is likely to result from
or occur during the transfer of the insured from a facility or to
deliver a newborn child (including the placenta).

(5) (A) (i) Every group or blanket policy delivered or issued for
delivery in this state which provides hospital, surgical or medical
coverage shall include coverage for maternity care, including hospital,
surgical or medical care to the same extent that coverage is provided
for illness or disease under the policy. Such maternity care coverage,
other than coverage for perinatal complications, shall include inpatient
hospital coverage for mother and newborn for at least forty-eight hours
after childbirth for any delivery other than a caesarean section, and
for at least ninety-six hours after a caesarean section. Such coverage
for maternity care shall include the services of a midwife licensed
pursuant to article one hundred forty of the education law, practicing
consistent with section sixty-nine hundred fifty-one of the education
law and affiliated or practicing in conjunction with a facility licensed
pursuant to article twenty-eight of the public health law, but no
insurer shall be required to pay for duplicative routine services
actually provided by both a licensed midwife and a physician.

(ii) Maternity care coverage shall also include, at minimum, parent
education, assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.

(iii) The mother shall have the option to be discharged earlier than
the time periods established in item (i) of this subparagraph. In such
case, the inpatient hospital coverage must include at least one home
care visit which shall be in addition to, rather than in lieu of, any
home health care coverage available under the policy. The policy must
cover the home care visit, which may be requested at any time within
forty-eight hours of the time of delivery (ninety-six hours in the case
of caesarean section), and shall be delivered within twenty-four hours,
(I) after discharge, or (II) of the time of the mother's request,
whichever is later. Such home care coverage shall be pursuant to the
policy and subject to the provisions of this subparagraph, and not
subject to deductibles, coinsurance or copayments.

(B) Coverage provided under this paragraph for care and treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.

(6) (A) Every group policy issued or delivered in this state which
provides coverage for hospital care shall not exclude coverage for
hospital care for diagnosis and treatment of correctable medical
conditions otherwise covered by the policy solely because the medical
condition results in infertility; provided, however that:

(i) subject to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical or medical procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and

(ii) provided, further however, that subject to the provisions of
subparagraph (C) of this paragraph, in no case shall such coverage
exclude diagnostic tests and procedures provided as part of such
hospital care that are necessary to determine infertility or that are
necessary in connection with any surgical or medical treatments or
prescription drug coverage provided pursuant to this paragraph,
including such diagnostic tests and procedures as hysterosalpingogram,
hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post
coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
and

(iii) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.

(B) Every group policy issued or delivered in this state which
provides coverage for surgical and medical care shall not exclude
coverage for surgical and medical care for diagnosis and treatment of
correctable medical conditions otherwise covered by the policy solely
because the medical condition results in infertility; provided, however
that:

(i) subject to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical or medical procedures
which would correct malformation, disease or dysfunction resulting in
infertility; and

(ii) provided, further however, that subject to the provisions of
subparagraph (C) of this paragraph, in no case shall such coverage
exclude diagnostic tests and procedures that are necessary to determine
infertility or that are necessary in connection with any surgical or
medical treatments or prescription drug coverage provided pursuant to
this paragraph, including such diagnostic tests and procedures as
hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,
sono-hysterogram, post coital tests, testis biopsy, semen analysis,
blood tests and ultrasound; and

(iii) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.

(C) Coverage of diagnostic and treatment procedures, including
prescription drugs, used in the diagnosis and treatment of infertility
as required by subparagraphs (A) and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.

(i) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this subparagraph.

(ii) Coverage may be subject to co-payments, coinsurance and
deductibles as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy.

(iii) Except as provided in items (vi) and (vii) of this subparagraph,
coverage shall not be required to include the diagnosis and treatment of
infertility in connection with: (I) in vitro fertilization, gamete
intrafallopian tube transfers or zygote intrafallopian tube transfers;
(II) the reversal of elective sterilizations; (III) sex change
procedures; (IV) cloning; or (V) medical or surgical services or
procedures that are deemed to be experimental in accordance with
clinical guidelines referenced in item (iv) of this subparagraph.

(iv) The superintendent, in consultation with the commissioner of
health, shall promulgate regulations which shall stipulate the
guidelines and standards which shall be used in carrying out the
provisions of this subparagraph, which shall include:

(I) The identification of experimental procedures and treatments not
covered for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;

(II) The identification of the required training, experience and other
standards for health care providers for the provision of procedures and
treatments for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine; and

(III) The determination of appropriate medical candidates by the
treating physician in accordance with the standards and guidelines
established and adopted by the American College of Obstetricians and
Gynecologists and/or the American Society for Reproductive Medicine.

(v)(I) For the purposes of this paragraph, "infertility" means a
disease or condition characterized by the incapacity to impregnate
another person or to conceive, defined by the failure to establish a
clinical pregnancy after twelve months of regular, unprotected sexual
intercourse or therapeutic donor insemination, or after six months of
regular, unprotected sexual intercourse or therapeutic donor
insemination for a female thirty-five years of age or older. Earlier
evaluation and treatment may be warranted based on an individual's
medical history or physical findings.

(II) For purposes of this paragraph, "iatrogenic infertility" means an
impairment of fertility by surgery, radiation, chemotherapy or other
medical treatment affecting reproductive organs or processes.

(vi) Coverage shall also include standard fertility preservation
services when a medical treatment may directly or indirectly cause
iatrogenic infertility to an insured. Coverage may be subject to annual
deductibles and coinsurance, including copayments, as may be deemed
appropriate by the superintendent and as are consistent with those
established for other benefits within a given policy.

(vii) Every large group policy delivered or issued for delivery in
this state that provides medical, major medical or similar
comprehensive-type coverage shall provide coverage for three cycles of
in-vitro fertilization used in the treatment of infertility. Coverage
may be subject to annual deductibles and coinsurance, including
copayments, as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy. For purposes of this item, a "cycle" is defined as either all
treatment that starts when: preparatory medications are administered for
ovarian stimulation for oocyte retrieval with the intent of undergoing
in-vitro fertilization using a fresh embryo transfer; or medications are
administered for endometrial preparation with the intent of undergoing
in-vitro fertilization using a frozen embryo transfer.

(viii) No insurer providing coverage under this paragraph shall
discriminate based on an insured's expected length of life, present of
predicted disability, degree of medical dependency, perceived quality of
life, or other health conditions, nor based on personal characteristics,
including age, sex, sexual orientation, marital status or gender
identity.

(D) Every policy that provides coverage for prescription fertility
drugs and requires or permits prescription drugs to be purchased through
a network participating mail order or other non-retail pharmacy shall
provide the same coverage for prescription fertility drugs when such
drugs are purchased from a network participating non-mail order retail
pharmacy provided that the network participating non-mail order retail
pharmacy agrees in advance through a contractual network agreement, to
the same reimbursement amount, as well as the same applicable terms and
conditions, that the insurer has established for a network participating
mail order or other non-retail pharmacy. In such case, the policy shall
not impose any fee, co-payment, co-insurance, deductible or other
condition on any covered person who elects to purchase prescription
fertility drugs through a network participating non-mail order retail
pharmacy that it does not impose on any covered person who purchases
prescription fertility drugs through a network participating mail order
or other non-retail pharmacy; provided, however, that the provisions of
this section shall not supersede the terms of a collective bargaining
agreement or apply to a policy that is the result of a collective
bargaining agreement between an employer and a recognized or certified
employee organization.

(7)(A) Every group or blanket accident and health insurance policy
issued or issued for delivery in this state which provides medical
coverage that includes coverage for physician services in a physician's
office and every policy which provides major medical or similar
comprehensive-type coverage shall include coverage for the following
equipment and supplies for the treatment of diabetes, if recommended or
prescribed by a physician or other licensed health care provider legally
authorized to prescribe under title eight of the education law: blood
glucose monitors and blood glucose monitors for the visually impaired,
data management systems, test strips for glucose monitors and visual
reading and urine testing strips, insulin, injection aids, cartridges
for the visually impaired, syringes, insulin pumps and appurtenances
thereto, insulin infusion devices, and oral agents for controlling blood
sugar. In addition, the commissioner of the department of health shall
provide and periodically update by rule or regulation a list of
additional diabetes equipment and related supplies such as are medically
necessary for the treatment of diabetes, for which there shall also be
coverage. Such policies shall also include coverage for diabetes
self-management education to ensure that persons with diabetes are
educated as to the proper self-management and treatment of their
diabetic condition, including information on proper diets. Such coverage
for self-management education and education relating to diet shall be
limited to visits medically necessary upon the diagnosis of diabetes,
where a physician diagnoses a significant change in the patient's
symptoms or conditions which necessitate changes in a patient's
self-management, or where reeducation or refresher education is
necessary. Such education may be provided by the physician or other
licensed health care provider legally authorized to prescribe under
title eight of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by a certified diabetes
nurse educator, certified nutritionist, certified dietitian or
registered dietitian upon the referral of a physician or other licensed
health care provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified nutritionist, certified dietitian or registered
dietitian may be limited to group settings wherever practicable.
Coverage for self-management education and education relating to diet
shall also include home visits when medically necessary.

(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy;
provided however, the total amount that a covered person is required to
pay out of pocket for covered prescription insulin drugs shall be capped
at an amount not to exceed one hundred dollars per thirty-day supply,
regardless of the amount or type of insulin needed to fill such covered
person's prescription and regardless of the insured's deductible,
copayment, coinsurance or any other cost sharing requirement.

(C) This paragraph shall not apply to a policy which covers persons
employed in more than one state or the benefit structure of which was
the subject of collective bargaining affecting persons employed in more
than one state unless such policy is issued under the New York state
health insurance plan established under article eleven of the civil
service law or issued to or through a local government.

(8) (A) Every group or blanket policy delivered or issued for delivery
in this state which provides coverage for inpatient hospital care shall
provide such coverage for such period as is determined by the attending
physician in consultation with the patient to be medically appropriate
for such covered person undergoing a lymph node dissection or a
lumpectomy for the treatment of breast cancer or a mastectomy covered by
the policy. Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy. Written notice of the availability of such coverage shall be
delivered to the policyholder prior to inception of such policy and
annually thereafter.

(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:

(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;

(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or

(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.

(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.

(9)(A) Every policy which provides medical, major medical, or similar
comprehensive-type coverage must provide coverage for a second medical
opinion by an appropriate specialist, including but not limited to a
specialist affiliated with a specialty care center for the treatment of
cancer, in the event of a positive or negative diagnosis of cancer or a
recurrence of cancer or a recommendation of a course of treatment for
cancer, subject to the following:

(i) In the case of a policy that requires, or provides financial
incentives for, the insured to receive covered services from health care
providers participating in a provider network maintained by or under
contract with the insurer, the policy shall include coverage for a
second medical opinion from a non-participating specialist, including
but not limited to a specialist affiliated with a specialty care center
for the treatment of cancer, when the attending physician provides a
written referral to a non-participating specialist, at no additional
cost to the insured beyond what such insured would have paid for
services from a participating appropriate specialist. Provided, however
that nothing herein shall impair an insured's rights (if any) under the
policy to obtain the second medical opinion from a non-participating
specialist without a written referral, subject to the payment of
additional coinsurance (if any) required by the policy for services
provided by non-participating providers. The insurer shall compensate
the non-participating specialist at the usual, customary and reasonable
rate, or at a rate listed on a fee schedule filed and approved by the
superintendent which provides a comparable level of reimbursement.

(ii) In the case of a policy that does not provide financial
incentives for, and does not require, the insured to receive covered
services from health care providers participating in a provider network
maintained by or under contract with the insurer, the policy shall
include coverage for a second medical opinion from a specialist at no
additional cost to the insured beyond what the insured would have paid
for comparable services covered under the policy.

(iii) Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy, and, where applicable, consistent with the provisions of clauses
(i) and (ii) of this subparagraph.

Nothing in this paragraph shall eliminate or diminish an insurer's
obligation to comply with the provisions of section four thousand eight
hundred four of this chapter where applicable. Written notice of the
availability of such coverage shall be delivered to the policyholder
prior to the inception of such policy and annually thereafter.

(B) An insurer providing coverage under this paragraph and any
participating entity through which an insurer offers health services
shall not:

(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;

(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph; or

(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the coverage provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph.

(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.

(10)(A) Every group or blanket policy delivered or issued for delivery
in this state which provides medical, major medical, or similar
comprehensive-type coverage shall provide the following coverage for
breast reconstruction surgery after a mastectomy or partial mastectomy:

(i) all stages of reconstruction of the breast on which the mastectomy
or partial mastectomy has been performed; and

(ii) surgery and reconstruction of the other breast to produce a
symmetrical appearance;
in the manner determined by the attending physician and the patient to
be appropriate. Such coverage may be subject to annual deductibles and
coinsurance provisions as may be deemed appropriate by the
superintendent and as are consistent with those established for other
benefits within a given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such policy and annually thereafter.

(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:

(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;

(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or

(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.

(C) The prohibitions in this paragraph shall be in addition to the
provisions of sections three thousand two hundred thirty-one and three
thousand two hundred thirty-two of this article and nothing in this
paragraph shall be construed to suspend, supersede, amend or otherwise
modify such sections.

* (11) Every policy that provides coverage for prescription drugs
shall include coverage for the cost of enteral formulas for home use,
whether administered orally or via tube feeding, for which a physician
or other licensed health care provider legally authorized to prescribe
under title eight of the education law has issued a written order. Such
written order shall state that the enteral formula is clearly medically
necessary and has been proven effective as a disease-specific treatment
regimen. Specific diseases and disorders for which enteral formulas have
been proven effective shall include, but are not limited to, inherited
diseases of amino-acid or organic acid metabolism; Crohn's Disease;
gastroesophageal reflux; disorders of gastrointestinal motility such as
chronic intestinal pseudo-obstruction; and multiple, severe food
allergies including, but not limited to immunoglobulin E and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders and
impaired absorption of nutrients caused by disorders affecting the
absorptive surface, function, length, and motility of the
gastrointestinal tract. Enteral formulas that are medically necessary
and taken under written order from a physician for the treatment of
specific diseases shall be distinguished from nutritional supplements
taken electively. Coverage for certain inherited diseases of amino acid
and organic acid metabolism as well as severe protein allergic
conditions shall include modified solid food products that are low
protein, contain modified protein, or are amino acid based that are
medically necessary.

* NB There are 2 par (11)'s

* (11)(A) Every policy which is a "managed care product" as defined in
subparagraph (D) of this paragraph that includes coverage for physician
services in a physician's office, and every policy which is a "managed
care product" that provides major medical or similar comprehensive-type
coverage shall include coverage for chiropractic care, as defined in
section six thousand five hundred fifty-one of the education law,
provided by a doctor of chiropractic licensed pursuant to article one
hundred thirty-two of the education law, in connection with the
detection or correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for the purpose
of removing nerve interference, and the effects thereof, where such
interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column. However, chiropractic care
and services may be subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits, and reasonable
utilization review, provided that any such amounts, limits and review:
(a) shall not function to direct treatment in a manner discriminative
against chiropractic care, and (b) individually and collectively shall
be no more restrictive than those applicable under the same policy to
care or services provided by other health professionals in the
diagnosis, treatment and management of the same or similar conditions,
injuries, complaints, disorders or ailments, even if differing
nomenclature is used to describe the condition, injury, complaint,
disorder or ailment. Nothing herein contained shall be construed as
impeding or preventing either the provision or coverage of chiropractic
care and services by duly licensed doctors of chiropractic, within the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.

(C) Every policy which includes coverage for physician services in a
physician's office, and every policy which provides major medical or
similar comprehensive-type coverage, other than a "managed care product"
as defined in subparagraph (D) of this paragraph, shall provide coverage
for chiropractic care, as defined in section six thousand five hundred
fifty-one of the education law, provided by a doctor of chiropractic
licensed pursuant to article one hundred thirty-two of the education
law, in connection with the detection or correction by manual or
mechanical means of structural imbalance, distortion or subluxation in
the human body for the purpose of removing nerve interference, and the
effects thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of or in the vertebral column.
However, chiropractic care and services may be subject to reasonable
deductible, co-payment and co-insurance amounts, reasonable fee or
benefit limits, and reasonable utilization review, provided that any
such amounts, limits and review: (a) shall not function to direct
treatment in a manner discriminative against chiropractic care, and (b)
individually and collectively shall be no more restrictive that those
applicable under the same policy to care or services provided by other
health professionals in the diagnosis, treatment and management of the
same or similar conditions, injuries, complaints, disorders or ailments,
even if differing nomenclature is used to describe the condition,
injury, complaint, disorder or ailment. Nothing herein contained shall
be construed as impeding or preventing either the provision or coverage
of chiropractic care and services by duly licensed doctors of
chiropractic, within the lawful scope of chiropractic practice, in
hospital facilities on a staff or employee basis.

(D) For purposes of this paragraph, a "managed care product" shall
mean a policy which requires that medical or other health care services
covered under the policy, other than emergency care services, be
provided by, or pursuant to a referral from, a primary care provider,
and that services provided pursuant to such a referral be rendered by a
health care provider participating in the insurer's managed care
provider network. In addition, a managed care product shall also mean
the in-network portion of a contract which requires that medical or
other health care services covered under the contract, other than
emergency care services, be provided by, or pursuant to a referral from,
a primary care provider, and that services provided pursuant to such a
referral be rendered by a health care provider participating in the
insurer's managed care provider network, in order for the insured to be
entitled to the maximum reimbursement under the contract.

(E) The coverage required by this paragraph shall not be abridged by
any regulation promulgated by the superintendent.

* NB There are 2 par (11)'s

(12) No policy of group or blanket accident and health insurance
delivered or issued for delivery in this state shall exclude coverage of
a health care service, as defined in paragraph two of such subdivision
(e) of section four thousand nine hundred of this chapter, rendered or
proposed to be rendered to an insured on the basis that such service is
experimental or investigational, is rendered as part of a clinical trial
as defined in subsection (b-2) of section forty-nine hundred of this
chapter, or a prescribed pharmaceutical product referenced in
subparagraph (B) of paragraph two of subsection (e) of section
forty-nine hundred of this chapter provided that coverage of the patient
costs of such service has been recommended for the insured by an
external appeal agent upon an appeal conducted pursuant to subparagraph
(B) of paragraph four of subsection (b) of section four thousand nine
hundred fourteen of this chapter. The determination of the external
appeal agent shall be binding on the parties. For purposes of this
paragraph, patient costs shall have the same meaning as such term has
for purposes of subparagraph (B) of paragraph four of subsection (b) of
section four thousand nine hundred fourteen of this chapter; provided,
however, that coverage for the services required under this paragraph
shall be provided subject to the terms and conditions generally
applicable to other benefits provided under the policy.

(13) Every group or blanket policy delivered or issued for delivery in
this state that provides major medical or similar comprehensive-type
coverage shall provide such coverage for bone mineral density
measurements or tests, and if such contract otherwise includes coverage
for prescription drugs, drugs and devices approved by the federal food
and drug administration or generic equivalents as approved substitutes.
In determining appropriate coverage provided by subparagraphs (A), (B)
and (C) of this paragraph, the insurer or health maintenance
organization shall adopt standards that include the criteria of the
federal Medicare program and the criteria of the national institutes of
health for the detection of osteoporosis, provided that such coverage
shall be further determined as follows:

(A) for purposes of subparagraphs (B) and (C) of this paragraph, bone
mineral density measurements or tests, drugs and devices shall include
those covered under the federal Medicare program as well as those in
accordance with the criteria of the national institutes of health,
including, as consistent with such criteria, dual-energy x-ray
absorptiometry.

(B) for purposes of subparagraphs (A) and (C) of this paragraph, bone
mineral density measurements or tests, drugs and devices shall be
covered for individuals meeting the criteria under the federal Medicare
program or the criteria of the national institutes of health; provided
that, to the extent consistent with such criteria, individuals
qualifying for coverage shall at a minimum, include individuals:

(i) previously diagnosed as having osteoporosis or having a family
history of osteoporosis; or

(ii) with symptoms or conditions indicative of the presence, or the
significant risk, of osteoporosis; or

(iii) on a prescribed drug regimen posing a significant risk of
osteoporosis; or

(iv) with lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or

(v) with such age, gender and/or other physiological characteristics
which pose a significant risk for osteoporosis.

(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given policy.

(D) In addition to subparagraph (A), (B) or (C) of this paragraph,
every group or blanket policy that provides hospital, surgical or
medical care coverage, except for a grandfathered health plan under
subparagraph (E) of this paragraph, shall provide coverage for the
following items or services for bone mineral density and such coverage
shall not be subject to annual deductibles or coinsurance:

(i) evidence-based items or services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations of
the United States preventive services task force; and

(ii) with respect to women, such additional preventive care and
screenings for bone mineral density not described in item (i) of this
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.

(E) For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was enrolled on
March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).

(14) No group or blanket policy delivered or issued for delivery in
this state which provides medical, major medical or similar
comprehensive-type coverage shall exclude coverage for services covered
under such policy when provided by a comprehensive care center for
eating disorders pursuant to article thirty of the mental hygiene law;
provided, however, that reimbursement under such policy for services
provided through such comprehensive care centers shall, to the extent
possible and practicable, be structured in a manner to facilitate the
individualized, comprehensive and integrated plans of care which such
centers' network of practitioners and providers are required to provide.

(15)(A) No group or blanket managed care health insurance policy that
provides coverage for hospital, medical or surgical care shall provide
that services of a participating hospital will be covered as
out-of-network services solely on the basis that the health care
provider admitting or rendering services to the insured is not a
participating provider.

(B) No group or blanket managed care health insurance policy that
provides coverage for hospital, medical or surgical care shall provide
that services of a participating health care provider will be covered as
out-of-network services solely on the basis that the services are
rendered in a non-participating hospital.

(C) For purposes of this paragraph, a "health care provider" is a
health care professional licensed, registered or certified pursuant to
title eight of the education law or a health care professional
comparably licensed, registered or certified by another state.

(D) For purposes of this paragraph, a "managed care health insurance
policy" is a policy that requires that services be provided by a
provider participating in the insurer's network in order for the insured
to receive the maximum level of reimbursement under the policy.

(16)(A) Every group or blanket policy that includes coverage for
dialysis treatment that requires such services to be provided by an
in-network provider and that does not provide coverage for
out-of-network dialysis treatment shall not deny coverage of such
services because the services are provided by an out-of-network
provider, provided that each of the following conditions are met:

(i) The out-of-network provider is duly licensed to practice and
authorized to provide such treatment;

(ii) The out-of-network provider is located outside the service area
of the insurer;

(iii) The in-network healthcare provider treating the insured for the
condition issues a written order for dialysis treatment stating that in
his or her opinion such treatment is necessary;

(iv) The insured has notified, in writing, the insurer at least thirty
days in advance of the proposed date or dates of such out-of-network
dialysis treatment. The notice shall include the authorization required
by clause (iii) of this subparagraph. In the event the insured must
travel on sudden notice due to family or other emergency, shorter notice
may be permitted, provided that the insurer has reasonable opportunity
to review the travel and treatment plans of the insured;

(v) The insurer shall have the right to pre-approve the dialysis
treatment and schedule; and

(vi) Such coverage is limited to no greater than ten out-of-network
treatments in a calendar year.

(B) Where coverage for out-of-network dialysis treatment is provided
pursuant to subparagraph (A) of this paragraph, no insurer shall be
obligated to reimburse the out-of-network provider at an amount greater
than it would have paid for the same treatment within a network,
including all drugs and ancillary services tied to dialysis treatment,
and any amount charged by a provider in excess of the amount reimbursed
by the insurer shall be the responsibility of the insured receiving the
out-of-network services.

(C) Such coverage of out-of-network dialysis services required by
subparagraph (A) of this paragraph shall otherwise be subject to the
limitations, exclusions and terms of the policy, including, but not
limited to, utilization review, annual deductibles, copayments, and
coinsurance, consistent with those required for other similar benefits
under the policy.

(17) Notwithstanding title eleven of article five of the social
services law or any other law to the contrary, every policy which
provides coverage for prescription drugs shall, with regard to eye drop
medication requiring a prescription that has been approved by the
insurer for coverage, allow for the limited refilling of the
prescription prior to the last day of the approved dosage period without
regard to any coverage restrictions on early refill of renewals.
Provided, however, that any refill dispensed prior to the expiration of
the prescribed and approved coverage period pursuant to this paragraph,
shall, to the extent practicable, be limited in quantity so as not to
exceed the remaining dosage initially approved for coverage. Provided,
further, that such limited refilling shall not limit or restrict
coverage with regard to any previously or subsequently approved
prescription for eye drop medication and shall be subject to the terms
and conditions of the policy otherwise applicable to this coverage.
Provided, further, that a pharmacist may contact the prescribing
physician or health care provider to verity the prescription.

(18) Every group or blanket policy which provides medical, major
medical or similar comprehensive-type coverage that includes coverage
for a physical or well care visit once in every three hundred sixty-five
days shall be interpreted to mean that such physical or well care visit
can be had once every calendar year, regardless of whether or not a
period of three hundred sixty-five days has passed since the previous
physical or well care visit.

(19) Every group or blanket accident and health insurance policy
delivered or issued for delivery in this state that provides medical
coverage that includes coverage for physician services in a physician's
office and every policy that provides major medical or similar
comprehensive-type coverage shall include coverage for equipment and
supplies used for the treatment of ostomies, if prescribed by a
physician or other licensed health care provider legally authorized to
prescribe under title eight of the education law. Such coverage shall be
subject to annual deductibles and coinsurance as deemed appropriate by
the superintendent. The coverage required by this paragraph shall be
identical to, and shall not enhance or increase the coverage required as
part of essential health benefits as defined in subsection (a) of
section three thousand two hundred seventeen-i of this article.

(20) No group or blanket policy delivered or issued for delivery in
this state that provides reimbursement for non-physician surgical first
assistant services when the services are provided by a non-physician
surgical first assistant shall exclude such coverage on the basis that
the non-physician surgical first assistant services were performed by a
registered nurse first assistant provided that: (A) the registered nurse
first assistant is certified in operating room nursing; (B) the services
are within the scope of practice of a non-physician surgical first
assistant; and (C) the terms and conditions of the policy otherwise
provide for the coverage of the services. Nothing in this paragraph
shall be construed to prevent the medical management or utilization
review of the services or prevent a policy from requiring that services
are to be provided through a network of participating providers who meet
certain requirements for participation, including provider
credentialing.

(21) Every group or blanket policy delivered or issued for delivery in
this state that provides coverage for prescription drugs subject to a
copayment shall charge a copayment for a limited initial prescription of
an opioid drug, which is prescribed in accordance with paragraph (b) of
subdivision five of section thirty-three hundred one of the public
health law, that is either (i) proportional between the copayment for a
thirty-day supply and the amount of drugs the patient was prescribed; or
(ii) equivalent to the copayment for a full thirty-day supply of the
opioid drug, provided that no additional copayments may be charged for
any additional prescriptions for the remainder of the thirty-day supply.

(l) (1) Every insurer delivering a group policy or issuing a group
policy for delivery in this state which provides coverage supplementing
part A and part B of subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq, must make available and, if requested by
the policyholder, provide coverage of supplemental home care visits
beyond those provided by part A and part B, sufficient to produce an
aggregate coverage of three hundred sixty-five home care visits per
policy year. Such coverage shall be provided pursuant to regulations
prescribed by the superintendent. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except that this notice
shall not be required where a policy covers two hundred or more
employees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.

(2) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides coverage for
in-patient hospital care must make available, and if requested by the
policyholder, provide coverage for care in a nursing home. Written
notice of the availability of such coverage shall be delivered to the
policyholder prior to inception of such group policy and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.

(B) Such coverage shall be made available at the inception of all new
policies and, with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.

(C) In this paragraph, care in a nursing home means the continued care
and treatment of a covered person who is under the care of a physician
but only if:

(i) the care is provided in a nursing home as defined in section
twenty-eight hundred one of the public health law or a skilled nursing
facility as defined in subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq;

(ii) the covered person has been in a hospital for at least three days
immediately preceding admittance to the nursing home or the skilled
nursing facility; and

(iii) further hospitalization would otherwise be necessary.

(D) In determining the total days of coverage for nursing home care
the aggregate of the number of covered days of care in a hospital and
the number of covered days of care in a nursing home, with two days of
care in a nursing home equivalent to one day of care in a hospital, need
not exceed the number of covered days of hospital care provided under
the contract in a benefit period.

(E) The level of benefits to be provided for nursing home care must be
reasonably related to the benefits provided for hospital care.

(3) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides coverage for
in-patient hospital care must make available and if requested by the
policyholder provide coverage to residents in this state for ambulatory
care in hospital out-patient facilities, as a hospital is defined in
section twenty-eight hundred one of the public health law, or subchapter
XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq, and
physicians' offices. Written notice of the availability of such coverage
shall be delivered to the policyholder prior to inception of such group
policy and annually thereafter, except that this notice shall not be
required where a policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.

(B) In this paragraph:

(i) "Ambulatory care in hospital out-patient facilities" means
services for diagnostic X-rays, laboratory and pathological
examinations, physical and occupational therapy and radiation therapy,
and services and medications used for nonexperimental cancer
chemotherapy and cancer hormone therapy, provided that such services and
medications are related to and necessary for the treatment or diagnosis
of the patient's illness or injury, are ordered by a physician and, in
the case of physical therapy services, are to be furnished in connection
with the same illness for which the patient had been hospitalized or in
connection with surgical care, but in no event need benefits for
physical therapy be provided which commences more than six months after
discharge from a hospital or the date surgical care was rendered, and in
no event need benefits for physical therapy be provided after three
hundred sixty-five days from the date of discharge from a hospital or
the date surgical care was rendered.

(ii) "Ambulatory care in physicians' offices" means services for
diagnostic X-rays, radiation therapy, laboratory and pathological
examinations, and services and medications used for nonexperimental
cancer chemotherapy and cancer hormone therapy, provided that such
services and medications are related to and necessary for the treatment
or diagnosis of the patient's illness or injury, and ordered by a
physician.

(C) Such coverage shall be made available at the inception of all new
policies and, with respect to policies issued before January first,
nineteen hundred eighty-three, at the first annual anniversary date
thereafter, without evidence of insurability and at any subsequent
annual anniversary date subject to evidence of insurability.

(4) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, that provides reimbursement for
psychiatric or psychological services or for the diagnosis and treatment
of mental health conditions, however defined in such policy, by
physicians, psychiatrists or psychologists, shall make available and if
requested by the policyholder provide the same coverage to insureds for
such services when performed by a licensed clinical social worker,
within the lawful scope of his or her practice, who is licensed pursuant
to article one hundred fifty-four of the education law. Written notice
of the availability of such coverage shall be delivered to the
policyholder prior to inception of such group policy and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.

(B) The state board for social work shall maintain a list of all
licensed clinical social workers qualified for reimbursement under this
paragraph.

(C) Such coverage shall be made available at the inception of all new
policies and, with respect to all other policies at any subsequent
annual anniversary date of the policy subject to evidence of
insurability.

(D) In addition to the requirements of subparagraph (A) of this
paragraph, every insurer issuing a group policy for delivery in this
state where the policy provides reimbursement to insureds for
psychiatric or psychological services or for the diagnosis and treatment
of mental health conditions, however defined in such policy, by
physicians, psychiatrists or psychologists, shall provide the same
coverage to insureds for such services when performed by a licensed
clinical social worker, within the lawful scope of his or her practice,
who is licensed pursuant to subdivision two of section seven thousand
seven hundred four of the education law and in addition shall have
either: (i) three or more additional years experience in psychotherapy,
which for the purposes of this subparagraph shall mean the use of verbal
methods in interpersonal relationships with the intent of assisting a
person or persons to modify attitudes and behavior that are
intellectually, socially or emotionally maladaptive, under supervision,
satisfactory to the state board for social work, in a facility, licensed
or incorporated by an appropriate governmental department, providing
services for diagnosis or treatment of mental health conditions; (ii)
three or more additional years experience in psychotherapy under the
supervision, satisfactory to the state board for social work, of a
psychiatrist, a licensed and registered psychologist or a licensed
clinical social worker qualified for reimbursement pursuant to
subsection (e) of this section, or (iii) a combination of the experience
specified in items (i) and (ii) of this subparagraph totaling three
years, satisfactory to the state board for social work.

(E) The state board for social work shall maintain a list of all
licensed clinical social workers qualified for reimbursement under
subparagraph (D) of this paragraph.

(5) (A) Every insurer delivering a group or school blanket policy or
issuing a group or school blanket policy for delivery, in this state,
which provides coverage for inpatient hospital care or coverage for
physician services shall provide coverage for the diagnosis and
treatment of mental health conditions and:

* (i) where the policy provides coverage for inpatient hospital care,
benefits for inpatient care in a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law and benefits for outpatient
care provided in a facility issued an operating certificate by the
commissioner of mental health pursuant to the provisions of article
thirty-one of the mental hygiene law, or in a facility operated by the
office of mental health or, for care provided in other states, to
similarly licensed or certified hospitals or facilities; and

* NB Effective until October 1, 2021

* (i) where the policy provides coverage for inpatient hospital care,
benefits for inpatient care in a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law and benefits for outpatient
care provided in a facility issued an operating certificate by the
commissioner of mental health pursuant to the provisions of article
thirty-one of the mental hygiene law, or in a facility operated by the
office of mental health or in a crisis stabilization center licensed
pursuant to section 36.01 of the mental hygiene law or, for care
provided in other states, to similarly licensed or certified hospitals
or facilities; and

* NB Effective October 1, 2021

(ii) where the policy provides coverage for physician services, it
shall include benefits for outpatient care provided by a psychiatrist or
psychologist licensed to practice in this state, a licensed clinical
social worker who meets the requirements of subparagraph (D) of
paragraph four of this subsection, a nurse practitioner licensed to
practice in this state, or a professional corporation or university
faculty practice corporation thereof.

(B) Coverage required by this paragraph may be subject to annual
deductibles, co-pays and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the policy. Provided that no copayment or coinsurance
imposed for outpatient mental health services provided in a facility
licensed, certified or otherwise authorized by the office of mental
health shall exceed the copayments or coinsurance imposed for a primary
care office visit under the policy.

(C) Coverage under this paragraph shall not apply financial
requirements or treatment limitations to mental health benefits that are
more restrictive than the predominant financial requirements and
treatment limitations applied to substantially all medical and surgical
benefits covered by the policy.

(D) The criteria for medical necessity determinations under the policy
with respect to mental health benefits shall be made available by the
insurer to any insured, prospective insured, or in-network provider upon
request.

(E) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;

(iii) "treatment limitation" means limits on the frequency of
treatment, number of visits, days of coverage, or other similar limits
on the scope or duration of treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on whether the
treatment is experimental or investigational; formulary design for
prescription drugs; network tier design; standards for provider
admission to participate in a network, including reimbursement rates;
methods for determining usual, customary, and reasonable charges;
fail-first or step therapy protocols; exclusions based on failure to
complete a course of treatment; and restrictions based on geographic
location, facility type, provider specialty, and other criteria that
limit the scope or duration of benefits for services provided under the
policy; and

(iv) "mental health condition" means any mental health disorder as
defined in the most recent edition of the diagnostic and statistical
manual of mental disorders or the most recent edition of another
generally recognized independent standard of current medical practice
such as the international classification of diseases.

(F) An insurer shall provide coverage under this paragraph, at a
minimum, consistent with the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a).

(G) This subparagraph shall apply to hospitals in this state that are
licensed by the office of mental health that are participating in the
insurer's provider network. Where the policy provides coverage for
inpatient hospital care, benefits for inpatient hospital care in a
hospital as defined by subdivision ten of section 1.03 of the mental
hygiene law provided to individuals who have not attained the age of
eighteen shall not be subject to preauthorization. Coverage provided
under this subparagraph shall also not be subject to concurrent
utilization review during the first fourteen days of the inpatient
admission, provided the facility notifies the insurer of both the
admission and the initial treatment plan within two business days of the
admission, performs daily clinical review of the patient, and
participates in periodic consultation with the insurer to ensure that
the facility is using the evidence-based and peer reviewed clinical
review criteria utilized by the insurer which is approved by the office
of mental health and appropriate to the age of the patient, to ensure
that the inpatient care is medically necessary for the patient. All
treatment provided under this subparagraph may be reviewed
retrospectively. Where care is denied retrospectively, an insured shall
not have any financial obligation to the facility for any treatment
under this subparagraph other than any copayment, coinsurance, or
deductible otherwise required under the policy.

* (H) This subparagraph shall apply to crisis stabilization centers in
this state that are licensed pursuant to section 36.01 of the mental
hygiene law and participate in the insurer's provider network. Benefits
for care in a crisis stabilization center shall not be subject to
preauthorization. All treatment provided under this subparagraph may be
reviewed retrospectively. Where care is denied retrospectively, an
insured shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.

* NB Effective October 1, 2021

(6) (A) Every policy that provides hospital, major medical or similar
comprehensive coverage shall provide inpatient coverage for the
diagnosis and treatment of substance use disorder, including
detoxification and rehabilitation services. Such inpatient coverage
shall include unlimited medically necessary treatment for substance use
disorder treatment services provided in residential settings. Further,
such inpatient coverage shall not apply financial requirements or
treatment limitations, including utilization review requirements, to
inpatient substance use disorder benefits that are more restrictive than
the predominant financial requirements and treatment limitations applied
to substantially all medical and surgical benefits covered by the
policy.

(B) Coverage provided under this paragraph may be limited to
facilities in New York state that are licensed, certified or otherwise
authorized by the office of alcoholism and substance abuse services and,
in other states, to those which are accredited by the joint commission
as alcoholism, substance abuse or chemical dependence treatment programs
and are similarly licensed, certified, or otherwise authorized in the
state in which the facility is located.

(C) Coverage provided under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other benefits within a
given policy.

(D) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of alcoholism
and substance abuse services that are participating in the insurer's
provider network. Coverage provided under this paragraph shall not be
subject to preauthorization. Coverage provided under this paragraph
shall also not be subject to concurrent utilization review during the
first twenty-eight days of the inpatient admission provided that the
facility notifies the insurer of both the admission and the initial
treatment plan within two business days of the admission. The facility
shall perform daily clinical review of the patient, including periodic
consultation with the insurer at or just prior to the fourteenth day of
treatment to ensure that the facility is using the evidence-based and
peer reviewed clinical review tool utilized by the insurer which is
designated by the office of alcoholism and substance abuse services and
appropriate to the age of the patient, to ensure that the inpatient
treatment is medically necessary for the patient. Prior to discharge,
the facility shall provide the patient and the insurer with a written
discharge plan which shall describe arrangements for additional services
needed following discharge from the inpatient facility as determined
using the evidence-based and peer-reviewed clinical review tool utilized
by the insurer which is designated by the office of alcoholism and
substance abuse services. Prior to discharge, the facility shall
indicate to the insurer whether services included in the discharge plan
are secured or determined to be reasonably available. Any utilization
review of treatment provided under this subparagraph may include a
review of all services provided during such inpatient treatment,
including all services provided during the first twenty-eight days of
such inpatient treatment. Provided, however, the insurer shall only deny
coverage for any portion of the initial twenty-eight day inpatient
treatment on the basis that such treatment was not medically necessary
if such inpatient treatment was contrary to the evidence-based and peer
reviewed clinical review tool utilized by the insurer which is
designated by the office of alcoholism and substance abuse services. An
insured shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.

(E) The criteria for medical necessity determinations under the policy
with respect to inpatient substance use disorder benefits shall be made
available by the insurer to any insured, prospective insured, or
in-network provider upon request.

(F) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;

(iii) "treatment limitation" means limits on the frequency of
treatment, number of visits, days of coverage, or other similar limits
on the scope or duration of treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on whether the
treatment is experimental or investigational; formulary design for
prescription drugs; network tier design; standards for provider
admission to participate in a network, including reimbursement rates;
methods for determining usual, customary, and reasonable charges;
fail-first or step therapy protocols; exclusions based on failure to
complete a course of treatment; and restrictions based on geographic
location, facility type, provider specialty, and other criteria that
limit the scope or duration of benefits for services provided under the
policy; and

(iv) "substance use disorder" shall have the meaning set forth in the
most recent edition of the diagnostic and statistical manual of mental
disorders or the most recent edition of another generally recognized
independent standard of current medical practice such as the
international classification of diseases.

(G) An insurer shall provide coverage under this paragraph, at a
minimum, consistent with the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a).

(7) (A) Every policy that provides medical, major medical or similar
comprehensive-type coverage shall provide outpatient coverage for the
diagnosis and treatment of substance use disorder, including
detoxification and rehabilitation services. Such coverage shall not
apply financial requirements or treatment limitations to outpatient
substance use disorder benefits that are more restrictive than the
predominant financial requirements and treatment limitations applied to
substantially all medical and surgical benefits covered by the policy.

* (B) Coverage under this paragraph may be limited to facilities in
New York state that are licensed, certified or otherwise authorized by
the office of alcoholism and substance abuse services to provide
outpatient substance use disorder services and, in other states, to
those which are accredited by the joint commission as alcoholism or
chemical dependence treatment programs and similarly licensed, certified
or otherwise authorized in the state in which the facility is located.

* NB Effective until October 1, 2021

* (B) Coverage under this paragraph may be limited to facilities in
this state that are licensed, certified or otherwise authorized by the
office of addiction services and supports to provide outpatient
substance use disorder services and crisis stabilization centers
licensed pursuant to section 36.01 of the mental hygiene law, and, in
other states, to those which are accredited by the joint commission as
alcoholism or chemical dependence treatment programs and similarly
licensed, certified or otherwise authorized in the state in which the
facility is located.

* NB Effective October 1, 2021

(C) Coverage provided under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other benefits within a
given policy.

(C-1) A large group policy that provides coverage under this paragraph
shall not impose copayments or coinsurance for outpatient substance use
disorder services that exceeds the copayment or coinsurance imposed for
a primary care office visit. Provided that no greater than one such
copayment may be imposed for all services provided in a single day by a
facility licensed, certified or otherwise authorized by the office of
alcoholism and substance abuse services to provide outpatient substance
use disorder services.

(D) A policy providing coverage for substance use disorder services
pursuant to this paragraph shall provide up to twenty outpatient visits
per policy or calendar year to an individual who identifies him or
herself as a family member of a person suffering from substance use
disorder and who seeks treatment as a family member who is otherwise
covered by the applicable policy pursuant to this paragraph. The
coverage required by this paragraph shall include treatment as a family
member pursuant to such family member's own policy provided such family
member:

(i) does not exceed the allowable number of family visits provided by
the applicable policy pursuant to this paragraph; and

(ii) is otherwise entitled to coverage pursuant to this paragraph and
such family member's applicable policy.

(E) This subparagraph shall apply to facilities in this state that are
licensed, certified or otherwise authorized by the office of alcoholism
and substance abuse services for the provision of outpatient, intensive
outpatient, outpatient rehabilitation and opioid treatment that are
participating in the insurer's provider network. Coverage provided under
this paragraph shall not be subject to preauthorization. Coverage
provided under this paragraph shall not be subject to concurrent review
for the first four weeks of continuous treatment, not to exceed
twenty-eight visits, provided the facility notifies the insurer of both
the start of treatment and the initial treatment plan within two
business days. The facility shall perform clinical assessment of the
patient at each visit, including periodic consultation with the insurer
at or just prior to the fourteenth day of treatment to ensure that the
facility is using the evidence-based and peer reviewed clinical review
tool utilized by the insurer which is designated by the office of
alcoholism and substance abuse services and appropriate to the age of
the patient, to ensure that the outpatient treatment is medically
necessary for the patient. Any utilization review of the treatment
provided under this subparagraph may include a review of all services
provided during such outpatient treatment, including all services
provided during the first four weeks of continuous treatment, not to
exceed twenty-eight visits, of such outpatient treatment. Provided,
however, the insurer shall only deny coverage for any portion of the
initial four weeks of continuous treatment, not to exceed twenty-eight
visits, for outpatient treatment on the basis that such treatment was
not medically necessary if such outpatient treatment was contrary to the
evidence-based and peer reviewed clinical review tool utilized by the
insurer which is designated by the office of alcoholism and substance
abuse services. An insured shall not have any financial obligation to
the facility for any treatment under this subparagraph other than any
copayment, coinsurance, or deductible otherwise required under the
policy.

(F) The criteria for medical necessity determinations under the policy
with respect to outpatient substance use disorder benefits shall be made
available by the insurer to any insured, prospective insured, or
in-network provider upon request.

(G) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;

(iii) "treatment limitation" means limits on the frequency of
treatment, number of visits, days of coverage, or other similar limits
on the scope or duration of treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on whether the
treatment is experimental or investigational; formulary design for
prescription drugs; network tier design; standards for provider
admission to participate in a network, including reimbursement rates;
methods for determining usual, customary, and reasonable charges;
fail-first or step therapy protocols; exclusions based on failure to
complete a course of treatment; and restrictions based on geographic
location, facility type, provider specialty, and other criteria that
limit the scope or duration of benefits for services provided under the
policy; and

(iv) "substance use disorder" shall have the meaning set forth in the
most recent edition of the diagnostic and statistical manual of mental
disorders or the most recent edition of another generally recognized
independent standard of current medical practice such as the
international classification of diseases.

(H) An insurer shall provide coverage under this paragraph, at a
minimum, consistent with the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a).

* (I) This subparagraph shall apply to crisis stabilization centers in
this state that are licensed pursuant to section 36.01 of the mental
hygiene law and participate in the insurer's provider network. Benefits
for care in a crisis stabilization center shall not be subject to
preauthorization. All treatment provided under this subparagraph may be
reviewed retrospectively. Where care is denied retrospectively, an
insured shall not have any financial obligation to the facility for any
treatment under this subparagraph other than any copayment, coinsurance,
or deductible otherwise required under the policy.

* NB Effective October 1, 2021

(7-a) (A) Every policy that provides medical, major medical or similar
comprehensive-type large group coverage shall provide immediate coverage
for all buprenorphine products, methadone or long acting injectable
naltrexone without prior authorization for the detoxification or
maintenance treatment of a substance use disorder.

(B) Coverage provided under this paragraph may be subject to
copayments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the policy.

(8) (A) Every insurer issuing a group policy for delivery in this
state that provides medical, major-medical or similar comprehensive-type
coverage shall provide coverage for the provision of preventive and
primary care services.

(B) In subparagraphs (A), (C) and (D) of this paragraph, preventive
and primary care services means the following services rendered to a
covered child of an insured from the date of birth through the
attainment of nineteen years of age:

(i) an initial hospital check-up and well-child visits scheduled in
accordance with the prevailing clinical standards of a national
association of pediatric physicians designated by the commissioner of
health (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service other than the
limits under state law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or under
the supervision of a physician, or other professional licensed under
article one hundred thirty-nine of the education law whose scope of
practice pursuant to such law includes the authority to provide the
specified services. Coverage shall be provided for such services
rendered in a hospital, as defined in section twenty-eight hundred one
of the public health law, or in an office of a physician or other
professional licensed under article one hundred thirty-nine of the
education law whose scope of practice pursuant to such law includes the
authority to provide the specified services;

(ii) at each visit, services in accordance with the prevailing
clinical standards of such designated association, including a medical
history, a complete physical examination, developmental assessment,
anticipatory guidance, appropriate immunizations and laboratory tests
which tests are ordered at the time of the visit and performed in the
practitioner's office, as authorized by law, or in a clinical
laboratory; and

(iii) necessary immunizations, as determined by the superintendent in
consultation with the commissioner of health, consisting of at least
adequate dosages of vaccine against diphtheria, pertussis, tetanus,
polio, measles, rubella, mumps, haemophilus influenzae type b and
hepatitis b, which meet the standards approved by the United States
public health service for such biological products.

(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not be subject to annual deductibles or coinsurance.

(D) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph shall not restrict or eliminate existing coverage provided by
the policy.

(E) In addition to subparagraph (A), (B), (C) or (D) of this
paragraph, every group policy that provides hospital, surgical or
medical care coverage, except for a grandfathered health plan under
subparagraph (G) of this paragraph, shall provide coverage for the
following preventive care and screenings for insureds, and such coverage
shall not be subject to annual deductibles or coinsurance:

(i) evidence-based items or services for preventive care and
screenings that have in effect a rating of 'A' or 'B' in the current
recommendations of the United States preventive services task force;

(ii) immunizations that have in effect a recommendation from the
advisory committee on immunization practices of the centers for disease
control and prevention with respect to the individual involved;

(iii) with respect to children, including infants and adolescents,
evidence-informed preventive care and screenings provided for in
comprehensive guidelines supported by the health resources and services
administration; and

(iv) with respect to women, such additional preventive care and
screenings not described in item (i) of this subparagraph and as
provided for in comprehensive guidelines supported by the health
resources and services administration.

(F) The requirements of this paragraph shall also be applicable to a
blanket policy of hospital, medical or surgical expense insurance
covering students pursuant to subparagraph (C) of paragraph three of
subsection (a) of section four thousand two hundred thirty-seven of this
chapter.

(G) For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was enrolled on
March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).

(9) Every insurer issuing a group policy for delivery in this state
which policy provides coverage for any service within the lawful scope
of practice of a duly licensed registered professional nurse, must make
available, and if requested by the contract holder, provide
reimbursement for such service when such service is performed by a duly
licensed registered professional nurse provided, however, that
reimbursement shall not be made for nursing services provided to an
insured in a general hospital, nursing home or a facility providing
health related services, as such terms are defined in section
twenty-eight hundred one of the public health law, or in a facility, as
such term is defined in subdivision six of section 1.03 of the mental
hygiene law, or in a physician's office. Such coverage may be subject to
annual deductibles and co-insurance as may be deemed appropriate by the
superintendent and are consistent with those imposed on other benefits
within a given policy. Such coverage shall not replace, restrict or
eliminate existing coverage provided by the policy. Coverage for the
services of a duly licensed registered professional nurse need be
provided only if the nature of the patient's illness or condition
requires nursing care which can appropriately be provided by a person
with the education and professional skill of a registered professional
nurse and the nursing care is necessary in the treatment of the
patient's illness or condition. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except that this notice
shall not be required where a policy covers two hundred or more
employees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.

(10) (A) Every insurer issuing a group policy for delivery in this
state which provides coverage for inpatient hospital care must make
available and if requested by the policyholder provide coverage for
hospice care. Written notice of the availability of such coverage shall
be delivered to the policyholder prior to inception of such group policy
and annually thereafter, except that this notice shall not be required
where a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.

(B) For the purposes of this paragraph, hospice care shall mean the
care and treatment of a covered person who has been certified by such
person's primary attending physician as having a life expectancy of six
months or less and which is provided by a hospice organization certified
pursuant to article forty of the public health law or under a similar
certification process required by the state in which the hospice
organization is located.

(C) Hospice care coverage shall be at least equal to: (i) a total of
two hundred ten days of coverage beginning with the first day on which
care is provided, for inpatient hospice care in a hospice or in a
hospital and home care and outpatient services provided by the hospice,
including drugs and medical supplies, and (ii) five visits for
bereavement counseling services, either before or after the insured's
death, provided to the family of the terminally ill insured.

(D) Such coverage shall be made available at the inception of all new
policies and, with respect to policies issued before the effective date
of this provision, at the first annual anniversary date thereafter,
without evidence of insurability and at any subsequent annual
anniversary date subject to evidence of insurability.

(E) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and are consistent
with those imposed on other benefits within a given policy period.

(11) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for delivery in this state that provides
coverage for hospital, surgical or medical care shall provide the
following coverage for mammography screening for occult breast cancer:

(i) upon the recommendation of a physician, a mammogram, which may be
provided by breast tomosynthesis, at any age for covered persons having
a prior history of breast cancer or who have a first degree relative
with a prior history of breast cancer;

(ii) a single baseline mammogram, which may be provided by breast
tomosynthesis, for covered persons aged thirty-five through thirty-nine,
inclusive;

(iii) an annual mammogram, which may be provided by breast
tomosynthesis, for covered persons aged forty and older; and

(iv) for large group policies that provide coverage for hospital,
surgical or medical care, an annual mammogram for covered persons aged
thirty-five through thirty-nine, inclusive, upon the recommendation of a
physician, subject to the insurer's determination that the mammogram is
medically necessary.

(B) Such coverage required pursuant to subparagraph (A) or (C) of this
paragraph shall not be subject to annual deductibles or coinsurance.

(C) For purposes of subparagraphs (A) and (B) of this paragraph,
mammography screening means an X-ray examination of the breast using
dedicated equipment, including X-ray tube, filter, compression device,
screens, films and cassettes, with an average glandular radiation dose
less than 0.5 rem per view per breast; provided, however, that
mammography screening shall also include breast tomosynthesis.

(D) In addition to subparagraph (A), (B) or (C) of this paragraph,
every group or blanket policy that provides coverage for hospital,
surgical or medical care, except for a grandfathered health plan under
subparagraph (E) of this paragraph, shall provide coverage for the
following mammography screening services, and such coverage shall not be
subject to annual deductibles or coinsurance:

(i) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and

(ii) with respect to women, such additional preventive care and
screenings for mammography not described in item (i) of this
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.

(E) For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was enrolled on
March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).

(F) Screening and diagnostic imaging for the detection of breast
cancer, including diagnostic mammograms, breast ultrasounds, or magnetic
resonance imaging, covered under the policy shall not be subject to
annual deductibles or coinsurance.

(11-a) (A) Every policy delivered or issued for delivery in this state
which provides medical coverage that includes coverage for physician
services in a physician's office and every policy which provides major
medical or similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized to prescribe
under title eight of the education law, the following coverage for
diagnostic screening for prostatic cancer:

(i) standard diagnostic testing including, but not limited to, a
digital rectal examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and

(ii) an annual standard diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen
test for men age fifty and over who are asymptomatic and for men age
forty and over with a family history of prostate cancer or other
prostate cancer risk factors.

(B) Such coverage shall not be subject to annual deductibles or
coinsurance.

(12) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for delivery in this state which provides
coverage for prescribed drugs approved by the food and drug
administration of the United States government for the treatment of
certain types of cancer shall not exclude coverage of any such drug on
the basis that such drug has been prescribed for the treatment of a type
of cancer for which the drug has not been approved by the food and drug
administration. Provided, however, that such drug must be recognized for
treatment of the specific type of cancer for which the drug has been
prescribed in one of the following established reference compendia:

(i) the American Hospital Formulary Service-Drug Information
(AHFS-DI);

(ii) National Comprehensive Cancer Networks Drugs and Biologics
Compendium;

(iii) Thomson Micromedex DrugDex;

(iv) Elsevier Gold Standard's Clinical Pharmacology; or other
authoritative compendia as identified by the Federal Secretary of Health
and Human Services or the Centers for Medicare & Medicaid Services
(CMS); or recommended by review article or editorial comment in a major
peer reviewed professional journal.

(B) Notwithstanding the provisions of this paragraph, coverage shall
not be required for any experimental or investigational drugs or any
drug which the food and drug administration has determined to be
contraindicated for treatment of the specific type of cancer for which
the drug has been prescribed. The provisions of this paragraph shall
apply to cancer drugs only and nothing herein shall be construed to
create, impair, alter, limit, modify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.

(12-a) (A) Every policy delivered or issued for delivery in this state
that provides medical, major medical, or similar comprehensive-type
coverage and provides coverage for prescription drugs and also provides
coverage for cancer chemotherapy treatment shall provide coverage for
prescribed, orally administered anticancer medications used to kill or
slow the growth of cancerous cells. Such coverage may be subject to
co-pays, coinsurance or deductibles, provided that the co-pays,
coinsurance or deductibles are at least as favorable to an insured as
the co-pays, coinsurance or deductibles that apply to coverage for
intravenous or injected anticancer medications.

(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:

(i) vary the terms of the policy for the purpose or with the effect of
avoiding compliance with this paragraph;

(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;

(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;

(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or

(v) achieve compliance with this paragraph by imposing an increase in
cost sharing for an intravenous or injected anticancer medication.

(13) Consistent with federal law every insurer delivering a group
policy or issuing a group policy for delivery in this state which
provides coverage supplementing part A and part B of subchapter XVIII of
the federal Social Security Act, 42 USC §§ 1395 et seq., shall make
available and, if requested by the policyholder, provide coverage for at
least ninety days of care in a nursing home as defined in section
twenty-eight hundred one of the public health law, except where such
coverage would duplicate coverage that is available under the
aforementioned subchapter XVIII. Such coverage shall be made available
at the inception of all new policies and, with respect to all other
policies at each anniversary date of the policy.

(A) Coverage shall be subject to a copayment of twenty-five dollars
per day.

(B) Brochures describing such coverage must be provided to the
policyholder at the inception of all new policies and thereafter on each
anniversary date of the policy, and with respect to all other policies
annually at each anniversary date of the policy. Such brochures must be
approved by the superintendent in consultation with the commissioner of
health.

(C) The commensurate rate for the coverage must be approved by the
superintendent.

(D) Such insurers shall report to the superintendent each year the
number of contract holders to whom such insurers have issued such
policies for nursing home coverage and the approximate number of persons
covered by such policies.

(14) (A) Every group or blanket policy delivered or issued for
delivery in this state that provides hospital, surgical or medical
coverage shall provide coverage for an annual cervical cytology
screening for cervical cancer and its precursor states for women aged
eighteen and older.

(B) For purposes of subparagraphs (A) and (C) of this paragraph,
cervical cytology screening shall include an annual pelvic examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services provided in connection with examining and evaluating the Pap
smear.

(C) Such coverage required pursuant to subparagraph (A) or (B) of this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given policy.

(D) In addition to subparagraph (A), (B) or (C) of this paragraph,
every group or blanket policy that provides hospital, surgical or
medical coverage, except for a grandfathered health plan under
subparagraph (E) of this paragraph, shall provide coverage for the
following cervical cytology screening services, and such coverage shall
not be subject to annual deductibles or coinsurance:

(i) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and

(ii) with respect to women, such additional preventive care and
screenings for cervical cytology not described in item (i) of this
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.

(E) For purposes of this paragraph, "grandfathered health plan" means
coverage provided by an insurer in which an individual was enrolled on
March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).

(15)(A) Every group or blanket policy delivered or issued for delivery
in this state which provides major medical or similar comprehensive-type
coverage shall include coverage for prehospital emergency medical
services for the treatment of an emergency condition when such services
are provided by an ambulance service issued a certificate to operate
pursuant to section three thousand five of the public health law.

(B) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against an insured for the services provided pursuant to
this paragraph, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms of
the policy.

(C) An insurer shall provide reimbursement for those services
prescribed by this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon rates, an
insurer shall pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.

(D) The provisions of this paragraph shall have no application to
transfers of patients between hospitals or health care facilities by an
ambulance service as described in subparagraph (A) of this paragraph.

(E) As used in this paragraph:

(i) "Prehospital emergency medical services" means the prompt
evaluation and treatment of an emergency medical condition, and/or
non-air-borne transportation of the patient to a hospital, provided
however, where the patient utilizes non-air-borne emergency
transportation pursuant to this paragraph, reimbursement shall be based
on whether a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of such
transportation to result in (I) placing the health of the person
affected with such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of such person or others in
serious jeopardy; (II) serious impairment to such person's bodily
functions; (III) serious dysfunction of any bodily organ or part of such
person; (IV) serious disfigurement of such person; or (V) a condition
described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
Social Security Act.

(ii) "Emergency condition" means a medical or behavioral condition
that manifests itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the
absence of immediate medical attention to result in (I) placing the
health of the person afflicted with such condition in serious jeopardy,
or in the case of a behavioral condition placing the health of such
person or others in serious jeopardy; (II) serious impairment to such
person's bodily functions; ( (III) serious dysfunction of any bodily
organ or part of such person; (IV) serious disfigurement of such person;
or (V) a condition described in clause (i), (ii) or (iii) of section
1867(e)(1)(A) of the Social Security Act.

(16) (A) Every group or blanket policy that provides medical, major
medical, or similar comprehensive type coverage that is issued, amended,
renewed, effective or delivered on or after January first, two thousand
twenty, shall provide coverage for all of the following services and
contraceptive methods:

(1) All FDA-approved contraceptive drugs, devices, and other products.
This includes all FDA-approved over-the-counter contraceptive drugs,
devices, and products as prescribed or as otherwise authorized under
state or federal law. The following applies to this coverage:

(a) where the FDA has approved one or more therapeutic and
pharmaceutical equivalent, as defined by the FDA, versions of a
contraceptive drug, device, or product, a group or blanket policy is not
required to include all such therapeutic and pharmaceutical equivalent
versions in its formulary, so long as at least one is included and
covered without cost-sharing and in accordance with this paragraph;

(b) if the covered therapeutic and pharmaceutical equivalent versions
of a drug, device, or product are not available or are deemed medically
inadvisable a group or blanket policy shall provide coverage for an
alternate therapeutic and pharmaceutical equivalent version of the
contraceptive drug, device, or product without cost-sharing. If the
attending health care provider, in his or her reasonable professional
judgment, determines that the use of a non-covered therapeutic or
pharmaceutical equivalent of a drug, device, or product is warranted,
the health care provider's determination shall be final. The
superintendent shall promulgate regulations establishing a process,
including timeframes, for an insured, an insured's designee or an
insured's health care provider to request coverage of a non-covered
contraceptive drug, device, or product. Such regulations shall include a
requirement that insurers use an exception form that shall meet criteria
established by the superintendent;

(c) this coverage shall include emergency contraception without
cost-sharing when provided pursuant to a prescription or order under
section sixty-eight hundred thirty-one of the education law or when
lawfully provided over the counter; and

(d) this coverage must allow for the dispensing of up to twelve months
worth of a contraceptive at one time;

(2) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and
identified in the comprehensive guidelines supported by the health
resources and services administration and thereby incorporated in the
essential health benefits benchmark plan;

(3) Patient education and counseling on contraception; and

(4) Follow-up services related to the drugs, devices, products, and
procedures covered under this paragraph, including, but not limited to,
management of side effects, counseling for continued adherence, and
device insertion and removal.

(B) A group or blanket policy subject to this paragraph shall not
impose a deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this paragraph.

(C) Except as otherwise authorized under this paragraph, a group or
blanket policy shall not impose any restrictions or delays on the
coverage required under this paragraph.

(D) Benefits for an enrollee under this paragraph shall be the same
for an enrollee's covered spouse or domestic partner and covered
nonspouse dependents.

(E) Notwithstanding any other provision of this subsection, a
religious employer may request a contract without coverage for federal
food and drug administration approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so requested,
such contract shall be provided without coverage for contraceptive
methods. This paragraph shall not be construed to deny an enrollee
coverage of, and timely access to, contraceptive methods.

(1) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:

(a) The inculcation of religious values is the purpose of the entity.

(b) The entity primarily employs persons who share the religious
tenets of the entity.

(c) The entity serves primarily persons who share the religious tenets
of the entity.

(d) The entity is a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.

(2) Every religious employer that invokes the exemption provided under
this paragraph shall provide written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.

(F) (1) Where a group policyholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with
subparagraph (E) of this paragraph each certificateholder covered under
the policy issued to that group policyholder shall have the right to
directly purchase the rider required by this paragraph from the insurer
which issued the group policy at the prevailing small group community
rate for such rider whether or not the employee is part of a small
group.

(2) Where a group policyholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with
subparagraph (E) of this paragraph, the insurer that provides such
coverage shall provide written notice to certificateholders upon
enrollment with the insurer of their right to directly purchase a rider
for coverage for the cost of contraceptive drugs or devices. The notice
shall also advise the certificateholders of the additional premium for
such coverage.

(G) Nothing in this paragraph shall be construed as authorizing a
group or blanket policy which provides coverage for prescription drugs
to exclude coverage for prescription drugs prescribed for reasons other
than contraceptive purposes.

(H) For the purposes of this paragraph, "over-the-counter
contraceptive products" shall mean those products provided for in
comprehensive guidelines supported by the health resources and services
administration as of January twenty-first, two thousand nineteen.

(17) (A) Every group or blanket accident and health insurance policy
delivered or issued for delivery in this state which provides coverage
for hospital or surgical care coverage shall not exclude coverage for
screening, diagnosis and treatment of medical conditions otherwise
covered by the policy because the treatment is provided to diagnose or
treat autism spectrum disorder.

(B) Every group or blanket policy that provides physician services,
medical, major medical or similar comprehensive-type coverage shall
provide coverage for the screening, diagnosis and treatment of autism
spectrum disorder in accordance with this paragraph and shall not
exclude coverage for the screening, diagnosis or treatment of medical
conditions otherwise covered by the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual deductibles, copayments and coinsurance as may be deemed
appropriate by the superintendent and shall be consistent with those
imposed on other benefits under the group or blanket policy. This
paragraph shall not be construed as limiting the benefits that are
otherwise available to an individual under the group or blanket policy,
provided however that such policy shall not contain any limitations on
visits that are solely applied to the treatment of autism spectrum
disorder. No insurer shall terminate coverage or refuse to deliver,
execute, issue, amend, adjust, or renew coverage to an individual solely
because the individual is diagnosed with autism spectrum disorder or has
received treatment for autism spectrum disorder. Coverage shall be
subject to utilization review and external appeals of health care
services pursuant to article forty-nine of this chapter as well as case
management and other managed care provisions.

(C) For purposes of this paragraph:

(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders.

(ii) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and
behavior.

(iii) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided by a person licensed, certified or otherwise
authorized to provide applied behavior analysis, that are necessary to
develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual.

(iv) "diagnosis of autism spectrum disorder" means assessments,
evaluations, or tests to diagnose whether an individual has autism
spectrum disorder.

(v) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.

(vi) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist
practices.

(vii) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the
psychologist practices.

(viii) "therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.

(ix) "treatment of autism spectrum disorder" shall include the
following care and assistive communication devices prescribed or ordered
for an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:

(1) behavioral health treatment;

(2) psychiatric care;

(3) psychological care;

(4) medical care provided by a licensed health care provider;

(5) therapeutic care, including therapeutic care which is deemed
habilitative or nonrestorative, in the event that the policy provides
coverage for therapeutic care; and

(6) pharmacy care in the event that the policy provides coverage for
prescription drugs.

(D) Coverage may be denied on the basis that such treatment is being
provided to the covered person pursuant to an individualized education
plan under article eighty-nine of the education law. The provision of
services pursuant to an individualized family service plan under section
twenty-five hundred forty-five of the public health law, an
individualized education plan under article eighty-nine of the education
law, or an individualized service plan pursuant to regulations of the
office for persons with developmental disabilities shall not affect
coverage under the policy for services provided on a supplemental basis
outside of an educational setting if such services are prescribed by a
licensed physician or licensed psychologist.

(E) Nothing in this paragraph shall be construed to affect any
obligation to provide services to an individual under an individualized
family service plan under section twenty-five hundred forty-five of the
public health law, an individualized education plan under article
eighty-nine of the education law, or an individualized service plan
pursuant to regulations of the office for persons with developmental
disabilities.

(F) Nothing in this paragraph shall be construed to affect any
obligation to provide coverage for otherwise-covered services solely on
the basis that the services constitute early intervention program
services pursuant to section three thousand two hundred thirty-five-a of
this article or an individualized service plan pursuant to regulations
of the office for persons with developmental disabilities.

(G) Nothing in this paragraph shall be construed to prevent a group or
blanket policy from providing services through a network of
participating providers who shall meet certain requirements for
participation, including provider credentialing.

(H) Coverage under this paragraph shall not apply financial
requirements or treatment limitations to autism spectrum disorder
benefits that are more restrictive than the predominant financial
requirements and treatment limitations applied to substantially all
medical and surgical benefits covered by the policy.

(I) The criteria for medical necessity determinations under the policy
with respect to autism spectrum disorder benefits shall be made
available by the insurer to any insured, prospective insured, or
in-network provider upon request.

(J) For purposes of this paragraph:

(i) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;

(ii) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement; and

(iii) "treatment limitation" means limits on the frequency of
treatment, number of visits, days of coverage, or other similar limits
on the scope or duration of treatment and includes nonquantitative
treatment limitations such as: medical management standards limiting or
excluding benefits based on medical necessity, or based on whether the
treatment is experimental or investigational; formulary design for
prescription drugs; network tier design; standards for provider
admission to participate in a network, including reimbursement rates;
methods for determining usual, customary, and reasonable charges;
fail-first or step therapy protocols; exclusions based on failure to
complete a course of treatment; and restrictions based on geographic
location, facility type, provider specialty, and other criteria that
limit the scope or duration of benefits for services provided under the
policy.

(K) An insurer shall provide coverage under this paragraph, at a
minimum, consistent with the federal Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a).

(18) Any insurer delivering a group or blanket policy or issuing a
group or blanket policy for delivery in this state that provides
coverage for prescription drugs shall permit each insured to fill any
covered prescription that may be obtained at a network participating
mail order or other non-retail pharmacy, at the insured's option, at a
network participating non-mail order retail pharmacy provided that the
network participating non-mail order retail pharmacy agrees in advance,
through a contractual network agreement, to the same reimbursement
amount, as well as the same applicable terms and conditions, that the
insurer has established for the network participating mail order or
other non-retail pharmacy. In such a case, the policy shall not impose a
co-payment fee or other condition on any insured who elects to purchase
drugs from a network participating non-mail order retail pharmacy which
is not also imposed on insureds electing to purchase drugs from a
network participating mail order or other non-retail pharmacy; provided,
however, that the provisions of this section shall not supersede the
terms of a collective bargaining agreement or apply to a policy that is
the result of a collective bargaining agreement between an employer and
a recognized or certified employee organization.

(19) Whenever in this section an insurer is required to provide
benefits with no coinsurance or deductible, the requirement only applies
with respect to participating providers in the insurer's network, or
with respect to non-participating providers, if the insurer does not
have a participating provider in the in-network benefits portion of its
network with the appropriate training and experience to meet the
particular health care needs of the insured pursuant to subsection (d)
of section three thousand two hundred seventeen-d of this article.

* (20) Health care forensic examinations performed pursuant to section
twenty-eight hundred five-i of the public health law covered under the
policy shall not be subject to annual deductibles or coinsurance.

* NB There are 2 par (20)'s

* (20) Every insurer delivering a group or blanket policy or issuing a
group or blanket policy for delivery in this state that provides
coverage for hospital, surgical or medical care shall provide the
following coverage for pasteurized donor human milk (PDHM), which may
include fortifiers as medically indicated, for inpatient use, for which
a licensed medical practitioner has issued an order for an infant who is
medically or physically unable to receive maternal breast milk or
participate in breast feeding or whose mother is medically or physically
unable to produce maternal breast milk at all or in sufficient
quantities or participate in breast feeding despite optimal lactation
support. Such infant shall: (i) have a documented birth weight of less
than one thousand five hundred grams; or (ii) have a congenital or
acquired condition that places the infant at a high risk for development
of necrotizing enterocolitis.

* NB There are 2 par (20)'s

(m) A group policy providing hospital, surgical or medical expense
insurance for other than accident only shall provide that if all or any
portion of the insurance on an employee or member insured under the
policy ceases because of termination of employment or membership in the
class or classes eligible for coverage under the policy, such employee
or member shall be entitled without evidence of insurability upon
application to continue his hospital, surgical or medical expense
insurance for himself or herself and his or her eligible dependents,
subject to all of the group policy's terms and conditions applicable to
those forms of benefits and to the following conditions:

(1) Continuation shall cease on the date which the employee, member or
dependant first becomes, after the date of election: (A) entitled to
coverage under title XVIII of the United States Social Security Act
(Medicare) as amended or superseded; or (B) covered as an employee,
member or dependent by any other insured or uninsured arrangement which
provides hospital, surgical or medical coverage for individuals in a
group which does not contain any exclusion or limitation with respect to
any pre-existing condition of such employee, member or dependent, except
the group insurance policy conversion option of this section shall not
be considered as such an arrangement under which an employee, member or
dependent could become covered.

(2) (A) An employee or member who wishes continuation of coverage must
request such continuation in writing within the sixty day period
following the later of: (i) the date of such termination; or (ii) the
date the employee is sent notice by first class mail of the right of
continuation by the group policyholder.

(B) An employee or member who wishes continuation of coverage under
subparagraph (D) of paragraph four of this subsection must give notice
to the employer or group policyholder within sixty days of the
determination under title II or title XVI of the United States Social
Security Act that such employee or member was disabled at the time of
termination of employment or membership or at any time during the first
sixty days of continuation of coverage.

(3) An employee or member electing continuation must pay to the group
policyholder or his employer, but not more frequently than on a monthly
basis in advance, the amount of the required premium payment, but not
more than one hundred two percent of the group rate for the benefits
being continued under the group policy on the due date of each payment.
The employee's or member's written election of continuation, together
with the first premium payment required to establish premium payment on
a monthly basis in advance, must be given to the policyholder or
employer within sixty days of the date the employee's or member's
benefits would otherwise terminate.

(4) Subject to paragraph one of this subsection, continuation of
benefits under the group policy for any person shall terminate at the
first to occur of the following:

(A) The date thirty-six months after the date the employee's or
member's benefits under the policy would otherwise have terminated
because of termination of employment or membership; or

(B) The end of the period for which premium payments were made, if the
employee or member fails to make timely payment of a required premium
payment; or

(C) In the case of an eligible dependent of an employee or member, the
date thirty-six months after the date such person's benefits under the
policy would otherwise have terminated by reason of:

(i) the death of the employee or member;

(ii) the divorce or legal separation of the employee or member from
his or her spouse;

(iii) the employee or member becoming entitled to benefits under title
XVIII of the United States Social Security Act (Medicare); or

(iv) a dependent child ceasing to be a dependent child under the
generally applicable requirements of the policy; or

(D) The date on which the group policy is terminated or, in the case
of an employee, the date his employer terminates participation under the
group policy. However, if this clause applies and the coverage ceasing
by reason of such termination is replaced by similar coverage under
another group policy, the following shall apply:

(i) The employee or member shall have the right to become covered
under that other group policy, for the balance of the period that he
would have remained covered under the prior group policy in accordance
with this subparagraph had a termination described in this subparagraph
not occurred, and

(ii) The minimum level of benefits to be provided by the other group
policy shall be the applicable level of benefits of the prior group
policy reduced by any benefits payable under that prior group policy,
and

(iii) The prior group policy shall continue to provide benefits to the
extent of its accrued liabilities and extension of benefits as if the
replacement had not occurred.

(5) A notification of the continuation privilege and the time period
in which to request continuation shall be included in each certificate
of coverage.

(6) This subsection shall not be applicable where a continuation
benefit is available to the employee or member pursuant to Chapter 18 of
the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or
Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et
seq. However, a group policy shall offer an insured who has exhausted
continuation coverage pursuant to Chapter 18 of the Employee Retirement
Income Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A of the
Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. the
opportunity to continue coverage for up to thirty-six months from the
date the employee's or member's continuation coverage began, if the
employee or member is entitled to less than thirty-six months of
continuation benefits under federal law.

(7)(A) Special enrollment period. An individual who does not have an
election of continuation coverage as described in this subsection in
effect on the effective date of the American Recovery and Reinvestment
act of 2009, but who would be an assistance eligible individual under
Title III of such act if such election were in effect, may elect
continuation coverage pursuant to this subsection. Such election shall
be made no later than sixty days after the date the administrator of the
group health plan (or other entity involved) provides the notice
required by section 3001(a)(7) of the American Recovery and Reinvestment
act of 2009. The administrator of the group health plan (or other entity
involved) shall provide such individuals with additional notice of the
right to elect coverage pursuant to this paragraph within sixty days of
the date of enactment of the American Recovery and Reinvestment act of
2009.

(B) Continuation coverage elected pursuant to subparagraph (A) of this
paragraph shall commence with the first period of coverage beginning on
or after the date of the enactment of the American Recovery and
Reinvestment act of 2009 and shall not extend beyond the period of
continuation coverage that would have been required if the coverage had
instead been elected pursuant to paragraph two of this subsection.

(C) With respect to an individual who elects continuation coverage
pursuant to subparagraph (A) of this paragraph, the period beginning on
the date of the qualifying event and ending on the date of the first
period of coverage on or after the enactment of the American Recovery
and Reinvestment act of 2009 shall be disregarded for purposes of
determining the sixty-three day period referred to in section three
thousand two hundred thirty-two of this article.

(8) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.

(n) In addition to all the rights of conversion and continuation
otherwise provided for herein, employees or members insured under the
policy who are also members of a reserve component of the armed forces
of the United States, including the National Guard, shall be entitled to
have supplementary conversion and continuation rights in certain
circumstances as follows:

(1) If the employee or member insured enters upon active duty as
defined in subsection (o) of this section, and the employer or group
policyholder does not voluntarily maintain coverage for such employee or
member insured, the employee or member insured shall be entitled to have
his or her coverage continued under the group policy in accordance with
the conditions and limitations contained in paragraph seven of this
subsection and have issued at the end of the period of continuation an
individual conversion policy subject to the terms of this subsection.
The effective date for the conversion policy shall be the day following
the termination of insurance under the group policy, or if there is a
continuation of coverage on the day following the end of the period of
continuation.

(2) If the employer or group policyholder does not voluntarily
maintain coverage for the employee or member insured during the period
of active duty, and such employee or member insured does not elect the
supplementary conversion and continuation rights provided for herein,
coverage for such employee or member insured shall be suspended during
the period of active duty.

(3) If the employee or member insured elects the supplementary
continuation right provided for herein or coverage under the group plan
is suspended, and such employee or member insured dies during the period
of active duty, the conversion right provided by this section shall be
available to the surviving spouse and children, and shall be available
to a child solely with respect to himself or herself upon his or her
attaining the limiting age of coverage under the group policy while
covered as a dependent thereunder. It shall also be available upon the
divorce or annulment of the marriage of the employee or member insured,
to the former spouse of such employee or member insured, if such divorce
or annulment occurs during the period of active duty.

(4) If the employee or member insured elects the supplementary
conversion and continuation right provided for herein or coverage under
the group plan is suspended, and such employee or member insured is
either reemployed or restored to participation in the group upon return
to civilian status, he or she shall be entitled to resume participation
in insurance offered by the group pursuant to this section, with no
limitations or conditions imposed as a result of such period of active
duty except as set forth in subparagraphs (A) and (B) herein. The right
of resumption provided for herein shall extend to coverage for the
spouse and dependents of the employee or member insured and shall be in
addition to other existing rights granted pursuant to state and federal
laws and regulations and shall not be deemed to qualify or limit such
rights in any way. No exclusion or waiting period may be imposed in
connection with coverage of a health or physical condition of a person
entitled to such right of resumption, or a health or physical condition
of any other person who is covered by the policy unless:

(A) the condition arose during the period of active duty and the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or

(B) a waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall the sum of the
waiting periods imposed prior to and subsequent to the period of
suspension exceed the length of the waiting period originally imposed.

(5) If the employee or member insured elects the supplementary
conversion and continuation coverage provided for herein:

(A) when such employee or member insured is either reemployed or
restored to participation in the group, coverage under the supplementary
rights provided for herein shall terminate on the date that coverage is
effective due to resumption of participation in the group.

(B) when such employee or member insured is not reemployed or restored
to participation in the group upon return to civilian status, he or she
shall be entitled to the conversion and continuation rights provided by
subsections (e) and (m) of this section.

(i) To elect an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must apply to the
insurer within thirty-one days of the termination of active duty or
discharge from hospitalization incident to such active duty, which
hospitalization continues for a period of not more than one year. Upon
commencement of coverage under the conversion right provided pursuant to
subsection (e) of this section, coverage under the supplementary
continuation right provided for herein shall terminate.

(ii) To elect continuation of coverage pursuant to subsections (e) and
(m) of this section, the employee or member insured must request such
continuation of the employer within thirty-one days of the termination
of active duty or discharge from hospitalization incident to such active
duty, which hospitalization continues for a period of not more than one
year. Upon commencement of coverage under the continuation right
provided pursuant to subsection (e) of this section, coverage under the
supplementary continuation right provided for herein shall terminate.
The employee or member insured shall be entitled to have issued at the
end of the period of continuation an individual conversion policy.

(6) If coverage under the group plan is suspended during the period of
active duty:

(A) when the employee or member insured returns to participation in
the group plan, coverage under the group plan shall be retroactive to
the date of termination of the period of active duty.

(B) when such employee or member insured is not reemployed or restored
to participation in the group upon return to civilian status, he or she
shall be entitled to the conversion and continuation rights provided by
subsections (e) and (m) of this section.

(i) To elect an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must apply to the
insurer within thirty-one days of the termination of active duty or
discharge from hospitalization incident to such active duty, which
hospitalization continues for a period of not more than one year.

(ii) To elect continuation of coverage pursuant to subsections (e) and
(m) of this section, the employee or member insured must request such
continuation of the employer within thirty-one days of the termination
of active duty or discharge from hospitalization incident to such active
duty, which hospitalization continues for a period of not more than one
year. The employee or member insured shall be entitled to have issued at
the end of the period of continuation an individual conversion policy.

(7) A group policy providing hospital, surgical or medical expense
insurance for other than accident only shall provide that if all or any
portion of the insurance on an employee or member insured under the
policy ceases because the employee or member insured is ordered to
active duty as defined in subsection (o) of this section, such employee
or member insured shall be entitled, without evidence of insurability,
upon application to continue his or her hospital, surgical or medical
expense insurance for himself or herself and his or her eligible
dependents, under the supplementary conversion and continuation rights
provided for herein, subject to all of the group policy's terms and
conditions applicable to those forms of benefits and to the following
conditions:

(A) continuation shall not be available for: (i) any person who is
covered, becomes covered or could be covered by title XVIII of the
United States Social Security Act (Medicare) as amended or superseded or
(ii) an employee, member or dependent who is covered, becomes covered or
could become covered as an employee, member or dependent by any other
insured or uninsured arrangement which provides hospital, surgical or
medical coverage for individuals in a group, except that the coverage
available to active duty members of the uniformed services and their
family members shall not be considered a group under the terms of this
subsection, and except that the group insurance policy conversion option
of this section shall not be considered as such an arrangement under
which an employee, member or dependent could become covered.

(B) an employee or member insured who wishes continuation of coverage
pursuant to this subsection must request such continuation in writing
within sixty days of being ordered to active duty.

(C) an employee or member insured electing continuation pursuant to
this subsection must pay to the group policyholder or his or her
employer, but not more frequently than on a monthly basis in advance,
the amount of the required premium payment, but not more than the group
rate for the benefits being continued under the group policy on the due
date of each payment.

(8) The supplementary conversion and continuation rights provided for
herein shall apply to:

(A) policies not covered by Chapter 18 of the Employee Retirement
Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the
Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;

(B) policies covered by Chapter 18 of the Employee Retirement Income
Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public
Health Service Act, 42 U.S.C. section 300bb-1 et seq, when active duty
for reservists and the refusal of an employer to voluntarily maintain
coverage for such period of active duty is not considered a qualifying
event.

(o) To be entitled to the right defined in subsection (n) of this
section a person must be a member of a reserve component of the armed
forces of the United States, including the National Guard, who either:

(A) voluntarily or involuntarily enters upon active duty (other than
for the purpose of determining his or her physical fitness and other
than for training), or

(B) has his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units of the
ready reserve or members of a reserve component to active duty, provided
that such additional active duty is at the request and for the
convenience of the federal government, and

(C) serves no more than four years of active duty.

(p)(1) Except as provided in this section, if an insurer delivers or
issues for delivery in this state a group or blanket policy which
provides hospital, surgical or medical expense coverage for other than
accident only, the insurer must renew or continue in force such coverage
at the option of the policyholder.

(2) An insurer may nonrenew or discontinue coverage under such a group
or blanket policy based only on one or more of the following:

(A) The policyholder or a participating entity has failed to pay
premiums or contributions in accordance with the terms of the policy or
the insurer has not received timely premium payments.

(B) The policyholder or a participating entity has performed an act or
practice that constitutes fraud or made an intentional misrepresentation
of material fact under the terms of the coverage.

(C) The policyholder has failed to comply with a material plan
provision relating to employer contribution or group participation
rules, as permitted under section four thousand two hundred thirty-five
of this chapter.

(D) The insurer is ceasing to offer group or blanket policies in a
market in accordance with paragraph three or seven of this subsection.

(E) The policyholder ceases to meet the requirements for a group under
section four thousand two hundred thirty-five of this chapter or a
participating employer, labor union, association or other entity ceases
membership or participation in the group to which the policy is issued.
Coverage terminated pursuant to this paragraph shall be done uniformly
without regard to any health status-related factor relating to any
covered individual.

(F) In the case of an insurer that offers a group or blanket policy in
a market through a network plan, there is no longer any enrollee in
connection with such plan who lives, resides, or works in the service
area of the insurer (or in the area for which the insurer is authorized
to do business).

(G) Such other reasons as are acceptable to the superintendent and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act.

(3)(A) In any case in which an insurer decides to discontinue offering
a particular class of group or blanket policy of hospital, surgical or
medical expense insurance offered in the small or large group market,
the policy of such class may be discontinued by the insurer in
accordance with this chapter in such market only if:

(i) the insurer provides written notice to each policyholder provided
coverage of this class in such market (and to all employees and member
insureds covered under such coverage) of such discontinuance at least
ninety days prior to the date of discontinuance of such coverage. In
addition to any other information required of notices by the
superintendent, this written notice shall conspicuously include an
explanation, in plain language, of the policyholder's and covered
employee's or member insured's rights under this subparagraph and (B) of
this paragraph, including:

(I) a statement that if the superintendent determines that the covered
employee, member insured, or a dependent has a serious medical
condition, and the covered employee, member insured or dependent within
the previous twelve months utilized a benefit under the policy related
to the serious medical condition that is not covered by the replacement
coverage offered to the policyholder as a result of the discontinuance,
then the superintendent shall require the insurer to offer the
policyholder replacement coverage that includes a benefit that is the
same as or substantially similar to the benefit set forth in the policy
that the insurer discontinued; and

(II) an explanation as to how to contact the superintendent, and the
date by which the superintendent shall be contacted, if the
policyholder, covered employee or member insured believes that the
covered employee, member insured or a dependent has a serious medical
condition, and the covered employee, member insured or dependent within
the previous twelve months utilized a benefit related to the serious
medical condition that may not be covered by the replacement coverage
offered to the policyholder as a result of the discontinuance;

(ii) the insurer offers to each policyholder provided coverage of this
class in such market, the option to purchase all (or, in the case of the
large group market, any) other hospital, surgical and medical expense
coverage currently being offered by the insurer to a group in such
market;

(iii) in exercising the option to discontinue coverage of this class
and in offering the option of coverage under item (ii) of this
subparagraph, the insurer acts uniformly without regard to the claims
experience of those policyholders or any health status-related factor
relating to any particular covered employee, member insured or dependent
or particular new employee, member insured or dependent who may become
eligible for such coverage, and the insurer is not discontinuing the
coverage of this class with the intent or as a pretext to discontinuing
the coverage of any such employee, member insured or dependent; and

(iv) at least ninety days prior to the date of discontinuance of such
coverage, the insurer provides written notice to the superintendent of
such discontinuance, including the reason for the discontinuance, and an
officer or director of the insurer certifies to the superintendent that
the insurer has complied with items (i), (ii) and (iii) of this
paragraph. If such notice does not include the date or dates that the
insurer mailed or delivered the notice to all policyholders, covered
employers and member insureds, the insurer shall notify the
superintendent of such date within seven days of the completion of the
mailing or delivery.

(B) If the superintendent determines that the insurer has not complied
with item (iii) of subparagraph (A) of this paragraph, then the
superintendent may prohibit the insurer from discontinuing the class of
policies and require the insurer to promptly notify every policyholder,
covered employee and member insured that the insurer is not
discontinuing the policies. If the superintendent determines that the
insurer wrongfully discontinued the class of policies pursuant to item
(iii) of subparagraph (A), then the superintendent shall require that
the insurer take remedial action, including offering to group
policyholders the option of reinstating the discontinued policy forms.
If the superintendent determines that the insurer discontinued the class
of policies without compliance with items (i), (ii), or (iv) of
subparagraph (A), and an employee, member insured or dependent covered
under the discontinued policy would have been entitled to relief under
this paragraph, then the superintendent may require that the insurer
offer replacement coverage to an affected policyholder consistent with
item (ii) of subparagraph (C) of this paragraph.

(C) (i) If, within forty-five days after the insurer mails or delivers
the written notice of discontinuance required by item (i) of
subparagraph (A) of this paragraph, the superintendent is notified by a
policyholder or covered employee or member insured that a covered
employee, member insured or dependent has a serious medical condition
and that a benefit utilized by the covered employee, member insured or
dependent within the previous twelve months related to the serious
medical condition may not be covered by the replacement coverage offered
to the policyholder as a result of the discontinuance, then the
superintendent shall, within twenty days of the notification, ask the
insurer to confirm that the covered employee, member insured or
dependent utilize a benefit within the previous twelve months to treat
the medical condition that the covered employee, member insured or
dependent asserts is a serious medical condition, and that the benefit
is not covered by the replacement coverage. The superintendent may
request such additional information as the superintendent may require.
The insurer shall provide all requested information to the
superintendent within five days of receipt of the request.

(ii) If, within twenty days of the superintendent's receipt of all
additional information requested from the insurer, the superintendent
determines that (I) the covered employee, member insured or dependent
has a serious medical condition; and (II) the benefit utilized by the
covered employee, member insured or dependent within the previous twelve
months related to the serious medical condition is not covered by the
replacement coverage offered to the policyholder as a result of the
discontinuance, then the superintendent shall require the insurer to
offer to the policyholder replacement coverage that includes a benefit
that is the same as or substantially similar to the benefit set forth in
the policy that the insurer discontinued. If the replacement coverage is
not available, at the time that the policy would otherwise be
discontinued, then the insurer shall keep the existing policy in force
for the affected policyholder until the replacement coverage with the
substantially similar benefit is available.

(D) The remedies as provided in this paragraph shall be in addition to
and not in lieu of any other authority or power of the superintendent to
impose monetary or other penalties for violations of this paragraph.

(E) In any case in which an insurer elects to discontinue offering all
hospital, surgical and medical expense coverage in the small group
market or the large group market, or both markets, in this state, health
insurance coverage may be discontinued by the insurer only if:

(i) the insurer provides written notice to the superintendent and to
each policyholder (and all employees and member insureds covered under
such coverage) of such discontinuance at least one hundred eighty days
prior to the date of the discontinuance of such coverage;

(ii) all hospital, surgical and medical expense coverage issued or
delivered for issuance in this state in such market (or markets) is
discontinued and coverage under such policies in such market (or
markets) is not renewed; and

(iii) in addition to the notice to the superintendent referred to in
item (i) of this subparagraph, the insurer shall provide the
superintendent with a written plan to minimize potential disruption in
the marketplace occasioned by the insurer's withdrawal from the market.

(F) In the case of a discontinuance under subparagraph (E of this
paragraph in a market, the insurer may not provide for the issuance of
any group or blanket policy of hospital, surgical or medical expense
insurance in that market in this state during the five year period
beginning on the date of the discontinuance of the last health insurance
policy not so renewed.

(4) At the time of coverage renewal, an insurer may modify the health
insurance coverage for a group or blanket policy offered to a large or
small group policyholder so long as such modification is consistent with
this chapter and effective on a uniform basis among all small group
policyholders with that policy form.

(5) For purposes of this subsection the term "network plan" shall mean
a health insurance policy under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract either with the insurer or another entity which has contracted
with the insurer.

(6) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.

(7) Notwithstanding paragraph three of this subsection, an insurer may
discontinue offering a particular class of group or blanket policy of
hospital, surgical or medical expense insurance offered in the small or
large group market, and instead offer a group or blanket policy of
hospital, surgical or medical expense insurance that complies with the
requirements of section 2707 of the public health service act, § 42
U.S.C. 300gg-6 that become applicable to such policy as of January
first, two thousand fourteen, provided that the insurer:

(A) discontinues the existing class of policy in such market as of
either December thirty-first, two thousand thirteen or the policy
renewal date occurring in two thousand fourteen in accordance with this
chapter;

(B) provides written notice to each policyholder provided coverage of
the class in the market (and to all employees and member insureds
covered under such coverage) of the discontinuance at least ninety days
prior to the date of discontinuance of such coverage. The written notice
shall be in a form satisfactory to the superintendent;

(C) offers to each policyholder provided coverage of the class in the
market, the option to purchase all (or, in the case of the large group
market, any) other hospital, surgical and medical expense coverage that
complies with the requirements of section 2707 of the public health
service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage
as of January first, two thousand fourteen, currently being offered by
the insurer to a group in that market;

(D) in exercising the option to discontinue coverage of the class and
in offering the option of coverage under subparagraph (C) of this
paragraph, acts uniformly without regard to the claims experience of
those policyholders or any health status-related factor relating to any
particular covered employee, member insured or dependent, or particular
new employee, member insured, or dependent who may become eligible for
such coverage, and does not discontinue the coverage of the class with
the intent or as a pretext to discontinuing the coverage of any such
employee, member insured, or dependent; and

(E) at least one hundred twenty days prior to the date of the
discontinuance of such coverage, provides written notice to the
superintendent of the discontinuance, including certification by an
officer or director of the insurer that the reason for the
discontinuance is to replace the coverage with new coverage that
complies with the requirements of section 2707 of the public health
service act, § 42 U.S.C. 300gg-6 that become effective January first,
two thousand fourteen. The written notice shall be in such form and
contain such information the superintendent requires.

(q)(1) No insurer delivering or issuing for delivery in this state a
group or blanket policy which provides hospital, surgical or medical
expense coverage shall establish rules for eligibility (including
continued eligibility) of any individual or dependent of the individual
to enroll under the policy based on any of the following health
status-related factors:

(A) Health status.

(B) Medical condition (including both physical and mental illnesses).

(C) Claims experience.

(D) Receipt of health care.

(E) Medical history.

(F) Genetic information.

(G) Evidence of insurability (including conditions arising out of acts
of domestic violence).

(H) Disability.

(2) For purposes of paragraph one of this subsection, rules for
eligibility include rules defining any applicable waiting periods for
such enrollment.

(3) No insurer may, on the basis of any health status-related factor
in relation to the insured or dependent of the insured, require any
insured (as a condition of enrollment or continued enrollment under the
policy) to pay a premium or contribution which is greater than such
premium for a similarly situated insured enrolled in the plan.

(4) Nothing in this subsection shall require an insurer to issue a
group or blanket policy to a group comprised of fifty-one or more lives
exclusive of spouses and dependents.

(5) Where an eligible insured or dependent of an insured rejects
initial enrollment in a group or blanket policy that provides hospital,
surgical or medical expense insurance, an insurer shall permit an
insured or dependent of an insured to enroll for coverage under the
terms of the policy if each of the following conditions is met:

(A) The insured or dependent was covered under another plan or policy
at the time coverage was initially offered.

(B)(i) Coverage under the other plan or policy was provided in
accordance with continuation required by federal or state law and was
exhausted; or

(ii) Coverage under the other plan or policy was subsequently
terminated as a result of loss of eligibility for one or more of the
following reasons:

(I) termination of employment;

(II) termination of the other plan or policy;

(III) death of the spouse;

(IV) legal separation, divorce, or annulment;

(V) reduction in the number of hours of employment; or

(iii) Policyholder contributions toward the payment of premium for the
other plan or contract were terminated.

(C) Coverage must be applied for within thirty days of termination for
one of the reasons set forth in subparagraph (B) of this paragraph.

(6) With respect to group or blanket policies delivered or issued for
delivery in this state covering between two and fifty employees or
members, the provisions of this subsection shall in no way diminish the
rights of such groups pursuant to section three thousand two hundred
thirty-one of this article.

(7) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (f) of section four thousand
two hundred thirty-five of this chapter.

(r) (1) As used in this subsection, "child" means an unmarried child
through age twenty-nine of an employee or member insured under a group
policy of hospital, medical or surgical expense insurance, regardless of
financial dependence, who is not insured by or eligible for coverage
under any employer health benefit plan as an employee or member, whether
insured or self-insured, and who lives, works or resides in New York
state or the service area of the insurer and who is not covered under
title XVIII of the United States Social Security Act (Medicare).

(2) In addition to the conversion privilege afforded by subsection (e)
of this section and the continuation privilege afforded by subsection
(m) of this section, every group policy delivered or issued for delivery
in this state that provides hospital, medical or surgical expense
insurance coverage for other than specific diseases or accidents only,
and which provides coverage of a child that terminates at a specified
age, shall, upon application of the employee, member or child, as set
forth in subparagraph (B) of this paragraph, provide coverage to the
child after that specified age and through age twenty-nine without
evidence of insurability, subject to all of the terms and conditions of
the group policy and the following:

(A) An employer shall not be required to pay all or part of the cost
of coverage for a child provided pursuant to this subsection;

(B) An employee, member or child who wishes to elect continuation of
coverage pursuant to this subsection shall request the continuation in
writing:

(i) within sixty days following the date coverage would otherwise
terminate due to reaching the specified age set forth in the group
policy;

(ii) within sixty days after meeting the requirements for child status
set forth in paragraph one of this subsection when coverage for the
child previously terminated; or

(iii) during an annual thirty-day open enrollment period, as described
in the policy;

(C) An employee, member or child electing continuation as described in
this subsection shall pay to the group policyholder or employer, but not
more frequently than on a monthly basis in advance, the amount of the
required premium payment on the due date of each payment. The written
election of continuation, together with the first premium payment
required to establish premium payment on a monthly basis in advance,
shall be given to the group policyholder or employer within the time
periods set forth in subparagraph (B) of this paragraph. Any premium
received within the thirty-day period after the due date shall be
considered timely;

(D) For any child electing coverage within sixty days of the date the
child would otherwise lose coverage due to reaching a specified age, the
effective date of the continuation coverage shall be the date coverage
would have otherwise terminated. For any child electing to resume
coverage during an annual open enrollment period, the effective date of
the continuation coverage shall be prospective no later than thirty days
after the election and payment of first premium;

(E) Coverage for a child pursuant to this subsection shall consist of
coverage that is identical to the coverage provided to the employee or
member parent. If coverage is modified under the policy for any group of
similarly situated employees or members, then the coverage shall also be
modified in the same manner for any child;

(F) Coverage shall terminate on the first to occur of the following:

(i) the date the child no longer meets the requirements of paragraph
one of this subsection;

(ii) the end of the period for which premium payments were made, if
there is a failure to make payment of a required premium payment within
the period of grace described in subparagraph (C) of this paragraph; or

(iii) the date on which the group policy is terminated and not
replaced by coverage under another group policy; and

(G) The insurer shall provide written notification of the continuation
privilege described in this subsection and the time period in which to
request continuation to the employee or member:

(i) in each certificate of coverage; and

(ii) at least sixty days prior to termination at the specified age as
provided in the policy.

(3)(A) Insurers shall submit such reports as may be requested by the
superintendent to evaluate the effectiveness of coverage pursuant to
this subsection including, but not limited to, quarterly enrollment
reports.

(B) The superintendent may promulgate regulations to ensure the
orderly implementation and operation of the continuation coverage
provided pursuant to this subsection, including premium rate
adjustments.

(s) An insurer subject to the provisions of this article or an
insurance producer subject to this chapter shall not permit the renewal
of a small group policy that provides hospital, surgical or medical
expense coverage that renews on or after January first, two thousand
fourteen, but before July first, two thousand fourteen, so as to renew
the same policy prior to the policy's annual renewal date for the sole
purpose of evading the requirements of the affordable care act and
regulations promulgated thereunder with respect to such policy. An
isolated, inadvertent renewal date change which was not made for the
sole purpose of evading the requirements of the affordable care act
shall not be deemed a violation of this subsection.

(t) (1) Any insurer that delivers or issues for delivery in this state
hospital, surgical or medical expense group policies in the small group
or large group market shall offer to any employer in this state all such
policies in the applicable market, and shall accept at all times
throughout the year any employer that applies for any of those policies.

(2) The requirements of paragraph one of this subsection shall apply
with respect to an employer that applies for coverage either directly
from the insurer or through an association or trust to which the insurer
has issued coverage and in which the employer participates.