New York Laws
Article 32 - Insurance Contracts - Life, Accident and Health, Annuities
3217-I - Essential Health Benefits Package and Limit on Cost-Sharing.

(A) ambulatory patient services;
(B) emergency services;
(C) hospitalization;
(D) maternity and newborn care;
(E) mental health and substance use disorder services, including
behavioral health treatment;
(F) prescription drugs;
(G) rehabilitative and habilitative services and devices;
(H) laboratory services;
(I) preventive and wellness services and chronic disease management;
and
(J) pediatric services, including oral and vision care.
(2) An insurer shall not be required to provide coverage for pediatric
oral services as an essential health benefit if:
(A) for coverage offered through the exchange established by this
state, the exchange has determined sufficient coverage of the pediatric
oral benefit is available through stand-alone dental plans certified by
the exchange; or
(B) for coverage offered outside the exchange, the insurer obtains
reasonable written assurance that the individual or group has obtained a
stand-alone dental plan that has been approved by the superintendent as
meeting exchange certification standards.
(b) (1) Every individual and small group accident and health insurance
policy that provides hospital, surgical, or medical expense coverage and
is not a grandfathered health plan shall provide coverage that meets the
actuarial requirements of one of the following levels of coverage:
(A) Bronze Level. A plan in the bronze level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to sixty percent of the full actuarial value of the benefits
provided under the plan;
(B) Silver Level. A plan in the silver level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to seventy percent of the full actuarial value of the
benefits provided under the plan;
(C) Gold Level. A plan in the gold level shall provide a level of
coverage that is designed to provide benefits that are actuarially
equivalent to eighty percent of the full actuarial value of the benefits
provided under the plan; or
(D) Platinum Level. A plan in the platinum level shall provide a level
of coverage that is designed to provide benefits that are actuarially
equivalent to ninety percent of the full actuarial value of the benefits
provided under the plan.
(2) The superintendent may provide for a variation in the actuarial
values used in determining the level of coverage of a plan to account
for the differences in actuarial estimates.
(3) Every student accident and health insurance policy shall provide
coverage that meets at least sixty percent of the full actuarial value
of the benefits provided under the policy. The policy's schedule of
benefits shall include the level as described in paragraph one of this
subsection nearest to, but below the actual actuarial value.
(c) Every individual or group accident and health insurance policy
that provides hospital, surgical, or medical expense coverage and is not
a grandfathered health plan, and every student accident and health
insurance policy shall limit the insured's cost-sharing for in-network
services in a policy year to not more than the maximum out-of-pocket

amount determined by the superintendent for all policies subject to this
section. Such amount shall not exceed any annual out-of-pocket limit on
cost-sharing set by the United States secretary of health and human
services, if available.
(d) The superintendent may require the use of model language
describing the coverage requirements for any accident and health
insurance policy form that is subject to the superintendent's approval
pursuant to section three thousand two hundred one of this article.
(e) For purposes of this section:
(1) "actuarial value" means the percentage of the total expected
payments by the insurer for benefits provided to a standard population,
without regard to the population to whom the insurer actually provides
benefits;
(2) "cost-sharing" means annual deductibles, coinsurance, copayments,
or similar charges, for covered services;
(3) "essential health benefits package" means coverage that:
(A) provides for essential health benefits;
(B) limits cost-sharing for such coverage in accordance with
subsection (c) of this section; and
(C) provides one of the levels of coverage described in subsection (b)
of this section;
(4) "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);
(5) "small group" means a group of one hundred or fewer employees or
members exclusive of spouses and dependents; and
(6) "student accident and health insurance" shall have the meaning set
forth in subsection (a) of section three thousand two hundred forty of
this article.

Structure New York Laws