(1) For preadmission testing performed in hospital facilities prior to
scheduled surgery. A patient who uses the out-patient facilities of a
hospital shall be entitled to benefits for tests ordered by a physician
which are performed as a planned preliminary to admission of the patient
as an in-patient for surgery in the same hospital, provided that:
(A) tests are necessary for and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed,
(B) reservations for a hospital bed and for an operating room shall
have been made prior to the performance of the tests,
(C) surgery actually takes place within seven days of such presurgical
tests, and
(D) the patient is physically present at the hospital for the tests.
(2) (A) For services to treat an emergency condition in hospital
facilities:
(i) without the need for any prior authorization determination;
(ii) regardless of whether the health care provider furnishing such
services is a participating provider with respect to such services;
(iii) if the emergency services are provided by a non-participating
provider, without imposing any administrative requirement or limitation
on coverage that is more restrictive than the requirements or
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 contract subject to this
paragraph.
(C) For the purpose of this provision, "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) For the purpose of this provision, "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) For the purpose of this provision, "to stabilize" means, with
respect to an emergency condition, to provide such medical treatment of
the condition as may be necessary to assure, within reasonable medical
probability, that no material deterioration of the condition is likely
to result from or occur during the transfer of the subscriber from a
facility or to deliver a newborn child (including the placenta).
(3) For home care to residents in this state. Such home care coverage
shall be included at the inception of all new contracts and, with
respect to all other contracts, added at any anniversary date of the
contract subject to evidence of insurability. Such coverage may be
subject to an annual deductible of not more than fifty dollars for each
covered person and may be subject to a coinsurance provision which
provides for coverage of not less than seventy-five percent of the
reasonable cost of services for which payment may be made. No such
corporation need provide such coverage to persons eligible for medicare.
(A) Home care shall mean the care and treatment of a covered person
who is under the care of a physician but only if:
(i) hospitalization or confinement in a nursing facility as defined in
subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq,
would otherwise have been required if home care was not provided, and
(ii) the plan covering the home health service is established and
approved in writing by such physician.
(B) 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.
(C) Home care 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, and
(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 or provided under the contract if the
covered person had been hospitalized or confined in a skilled nursing
facility as defined in subchapter XVIII of the Social Security Act, 42
U.S.C. § 1395 et seq.
(D) 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 covered person. Four hours of home health
aide service shall be considered as one home care visit. Every contract
issued by a hospital service corporation or health service corporation
which provides coverage supplementing part A and part B of subchapter
XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make
available and, if requested by a subscriber holding a direct payment
contract or by all subscribers in a group remittance group or by the
contract holder in the case of group contracts issued pursuant to
section four thousand three hundred five of this article, 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 contract 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 group remitting agent or group contract holder
prior to inception of such contract 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.
The provisions of this subsection shall not apply to a contract issued
pursuant to section four thousand three hundred five of this article
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) Every contract issued by a medical expense indemnity corporation
or a health service corporation 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 contract issued pursuant to section four thousand
three hundred five of this article 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.
(c) (1) (A) Every contract issued by a corporation subject to the
provisions of this article which provides hospital service, medical
expense indemnity or both shall provide coverage for maternity care
including hospital, surgical or medical care to the same extent that
hospital service, medical expense indemnity or both are provided for
illness or disease under the contract. Such maternity care coverage,
other than coverage for perinatal complications, shall include inpatient
hospital coverage for mother and for newborn for at least forty-eight
hours after childbirth for any delivery other than a caesarean section,
and for at least ninety-six hours following 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.
(B) Maternity care coverage also shall include, at minimum, parent
education, assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.
(C) The mother shall have the option to be discharged earlier than the
time periods established in subparagraph (A) of this paragraph. 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 contract. The contract
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
contract and subject to the provisions of this paragraph, and not
subject to deductibles, coinsurance or copayments.
(2) Coverage provided under this subsection 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.
(d) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and, if requested by a person holding a direct payment individual
contract or by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand three
hundred five of this article, provide coverage for care in nursing
homes. Such coverage shall be made available at the inception of all new
contracts and, with respect to all other contracts, at any anniversary
date subject to evidence of insurability. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract 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) For the purpose of this subsection, care in nursing homes shall
mean 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 two thousand 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. 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. The level of benefits
to be provided for nursing home care must be reasonably related to the
benefits provided for hospital care.
(e) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and, if requested by a person holding a direct payment individual
contract or by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand three
hundred five of this article, provide coverage for ambulatory care in
hospital out-patient facilities, as a hospital is defined in section two
thousand eight hundred one of the public health law, or subchapter XVIII
of the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of
the availability of such coverage shall be delivered to the group
remitting agent or group contract holder prior to inception of such
contract 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) For the purpose of this subsection, ambulatory care in hospital
out-patient facilities shall mean 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 (i) related to and necessary for
the treatment or diagnosis of the patient's illness or injury, (ii)
ordered by a physician and (iii) 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. Such coverage shall be made available at the inception of all
new contracts and, with respect to all other contracts, at any
anniversary date subject to evidence of insurability.
(f) (1) A medical expense indemnity corporation or a health service
corporation which provides coverage for physicians' services must make
available and, if requested by a person holding an individual direct
payment contract or by all persons holding individual contracts in a
group whose premiums are paid by a remitting agent or by the contract
holder in the case of a group contract issued pursuant to section four
thousand three hundred five of this article, provide coverage for
ambulatory care in physicians' offices. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract 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) For the purpose of this subsection, ambulatory care in physicians'
offices shall mean 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 (i) related to and
necessary for the treatment or diagnosis of the patient's illness or
injury, and (ii) ordered by a physician. Such coverage shall be made
available at the inception of all new contracts and, with respect to all
other contracts at any anniversary date subject to evidence of
insurability.
(g) A medical expense indemnity corporation, hospital service
corporation or a health service corporation, that provides group, group
remittance or school blanket coverage for inpatient hospital care or
coverage for physician services shall provide as part of its contract
coverage for the diagnosis and treatment of mental health conditions
and:
* (1) where the contract provides coverage for inpatient hospital
care, benefits for in-patient care in a hospital as defined by
subdivision ten of section 1.03 of the mental hygiene law or for
inpatient care provided in other states, to similarly licensed
hospitals, and benefits for out-patient 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 out-patient care provided in other states, to
similarly certified facilities; and
* NB Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the commissioner of
health have promulgated regulations
* (1) where the contract provides coverage for inpatient hospital
care, benefits for: in-patient care in a hospital as defined by
subdivision ten of section 1.03 of the mental hygiene law; sub-acute
care in a residential facility licensed or operated by the office of
mental health; outpatient care provided by 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 by a
facility operated by the office of mental health; outpatient care
provided by a crisis stabilization center licensed pursuant to section
36.01 of the mental hygiene law; outpatient care provided by a mobile
crisis intervention services provider licensed, certified, or designated
by the office of mental health or the office of addiction services and
supports; outpatient and inpatient care for critical time intervention
services and outpatient care for assertive community treatment services
provided by facilities issued an operating certificate by the
commissioner of mental health pursuant to the provisions of article
thirty-one of the mental hygiene law, beginning no later than thirty
days following discharge from a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law or the emergency department of
a hospital licensed pursuant to article twenty-eight of the public
health law; or for care provided in other states, to similarly licensed
or certified hospitals, facilities, or licensed, certified or designated
providers; and
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
(2) where the contract provides coverage for physician services such
contract shall provide benefits for outpatient care provided by a
psychiatrist or psychologist licensed to practice in this state, or a
mental health counselor, marriage and family therapist, or psychoanalyst
licensed pursuant to article one hundred sixty-three of the education
law, or 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, a nurse practitioner licensed to
practice in this state, or professional corporation or university
faculty practice corporation thereof. Nothing herein shall be construed
to modify or expand the scope of practice of a mental health counselor,
marriage and family therapist, or psychoanalyst licensed pursuant to
article one hundred sixty-three of the education law. Further, nothing
herein shall be construed to create a new mandated health benefit.
(3) Such coverage 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 contract.
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 contract.
(4) Coverage under this subsection 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 contract.
(5) The criteria for medical necessity determinations under the
contract with respect to mental health benefits shall be made available
by the corporation to any insured, prospective insured, or in-network
provider upon request.
(6) For purposes of this subsection:
(A) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;
* (C) "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
contract; and
* NB Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the commissioner of
health have promulgated regulations
* (C) "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
contract;
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
* (D) "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.
* NB Effective until January 1, 2025 and shall remain in effect until
after the superintendent of financial services and the commissioner of
health have promulgated regulations
* (D) "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;
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
* (E) "assertive community treatment services" means a comprehensive
and integrated combination of treatment, rehabilitation, case
management, and support services primarily provided in an insured's
residence or other community locations by a mobile multidisciplinary
mental health treatment team licensed pursuant to article thirty-one of
the mental hygiene law;
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
* (F) "critical time intervention services" means services rendered by
a provider licensed under article thirty-one of the mental hygiene law
that provides evidence-based, therapeutic interventions that include
intensive outreach, engagement, and care coordination services that are
provided to an insured before the insured is discharged from inpatient
care in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law or the emergency department of a hospital licensed
pursuant to article twenty-eight of the public health law and continue
after discharge until the insured is stabilized; and
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
* (G) "residential facility" means crisis residence facilities and
community residences for eating disorder integrated treatment programs
licensed pursuant to article thirty-one of the mental hygiene law.
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
(7) A corporation shall provide coverage under this subsection, 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).
* (8) This paragraph shall apply to hospitals in this state that are
licensed by the office of mental health that are participating in the
corporation's provider network. Where the contract 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 paragraph shall also not be subject to concurrent utilization
review during the first fourteen days of the inpatient admission,
provided the facility notifies the corporation 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 corporation to ensure that the facility
is using the evidence-based and peer reviewed clinical review criteria
utilized by the corporation 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 paragraph 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 paragraph other
than any copayment, coinsurance, or deductible otherwise required under
the contract.
* NB Effective until May 3, 2024
* (8) This paragraph shall apply to hospitals and crisis residence
facilities in this state that are licensed or operated by the office of
mental health that are participating in the corporation's provider
network. Where the contract 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 and benefits
for sub-acute care in a crisis residence facility licensed or operated
by the office of mental health shall not be subject to preauthorization.
Coverage provided under this paragraph shall also not be subject to
concurrent utilization review for individuals who have not attained the
age of eighteen during the first fourteen days of the inpatient
admission, provided the facility notifies the corporation of both the
admission and the initial treatment plan within two business days of the
admission, performs daily clinical review of the insured, and
participates in periodic consultation with the corporation to ensure
that the facility is using the evidence-based and peer reviewed clinical
review criteria utilized by the corporation which is approved by the
office of mental health and appropriate to the age of the insured, to
ensure that the inpatient care is medically necessary for the insured.
For individuals who have attained age eighteen, coverage provided under
this paragraph shall also not be subject to concurrent review during the
first thirty days of the inpatient or residential admission, provided
the facility notifies the corporation of both the admission and the
initial treatment plan within two business days of the admission,
performs daily clinical review of the insured, and participates in
periodic consultation with the corporation to ensure that the facility
is using the evidence-based and peer reviewed clinical review criteria
utilized by the corporation which is approved by the office of mental
health and appropriate to the age of the insured, to ensure that the
inpatient or residential care is medically necessary for the insured.
However, concurrent review may be performed during the first thirty days
if an insured meets clinical criteria designated by the office of mental
health or where the insured is admitted to a hospital or facility which
has been designated by the office of mental health for concurrent
review, in consultation with the commissioner of health and the
superintendent. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
* NB Effective May 3, 2024
* (9) This paragraph 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 corporation's provider network.
Benefits for care in a crisis stabilization center shall not be subject
to preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
* NB Effective until May 3, 2024
* (9) This paragraph 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 corporation's provider network.
Benefits for care by a crisis stabilization center shall not be subject
to preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
* NB Effective May 3, 2024
* (10) This paragraph shall apply to mobile crisis intervention
services providers licensed, certified, or designated by the office of
mental health or the office of addiction services and supports. For
purposes of this paragraph, "mobile crisis intervention services" means
mental health and substance use disorder services, consisting of: (1)
telephonic crisis triage and response; (2) mobile crisis response to
provide intervention and facilitate access to other behavioral health
services; and (3) mobile and telephonic follow-up services after the
initial crisis response until the insured is stabilized, provided to an
insured who is experiencing, or is at imminent risk of experiencing, a
behavioral health crisis, which includes instances in which an insured
cannot manage their primarily psychiatric or substance use related
symptoms without de-escalation or intervention. Mobile crisis
intervention services do not include services provided to an insured
after the insured has been stabilized.
(A) Benefits for covered services provided by a mobile crisis
intervention services provider shall not be subject to preauthorization.
Except where otherwise required by law, nothing in this paragraph shall
prevent services provided subsequent to the provision of mobile crisis
intervention services from being subject to preauthorization.
(B) Benefits for covered services provided by a mobile crisis
intervention services provider shall be covered regardless of whether
the mobile crisis intervention services provider is a participating
provider.
(C) If the covered services are provided by a non-participating mobile
crisis intervention services provider, a corporation shall not impose
any administrative requirement or limitation on coverage that is more
restrictive than the requirements or limitations that apply to covered
services received from a participating mobile crisis intervention
services provider.
(D) If the covered services are provided by a non-participating mobile
crisis intervention services provider, the insured's copayment,
coinsurance, and deductible shall be the same as would apply if such
covered services were provided by a participating mobile crisis
intervention services provider.
(E) A mobile crisis intervention services provider 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 subparagraph, except for the collection of in-network copayments,
coinsurance, or deductibles for which the insured is responsible for
under the terms of the contract.
* NB Effective January 1, 2025 but shall not take effect until after
the superintendent of financial services and the commissioner of health
have promulgated regulations
* (11) This paragraph shall apply to school-based mental health
clinics that are licensed pursuant to article thirty-one of the mental
hygiene law and provide outpatient care in pre-school, elementary, or
secondary schools. A corporation shall provide reimbursement for covered
outpatient care when provided by such school-based mental health clinics
at a pre-school, elementary, or secondary school, regardless of whether
the school-based mental health clinic furnishing such services is a
participating provider with respect to such services. Reimbursement for
such covered services shall be at the rate negotiated between the
corporation and school-based mental health clinic or, in the absence of
a negotiated rate, an amount no less than the rate that would be paid
for such services pursuant to the medical assistance program under title
eleven of article five of the social services law. Payment by a
corporation pursuant to this section shall be payment in full for the
services provided. The school-based mental health clinic reimbursed
pursuant to this section shall not charge or seek any reimbursement
from, or have any recourse against, a corporation for the services
provided pursuant to this paragraph, except for the collection of
in-network copayments, coinsurance, or deductibles for which the insured
is responsible for under the terms of the contract.
* NB Effective January 1, 2024
(j)(1) A health service corporation or medical expense indemnity
corporation that provides medical, major-medical or similar
comprehensive-type coverage shall provide coverage for the provision of
preventive and primary care services.
(2) For purposes of this paragraph and paragraph one of this
subsection, preventive and primary care services shall mean the
following services rendered to a covered child of a subscriber from the
date of birth through the attainment of nineteen years of age:
(A) 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,
(B) at each visit, services in accordance with the prevailing clinical
standards of such designated association, including a medical history, a
complete physical examination, developmental assessment, anticipatory
guidance, appropriate immunizations and laboratory tests which tests are
ordered at the time of the visit and performed in the practitioner's
office, as authorized by law, or in a clinical laboratory, and
(C) 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.
(D) Such coverage required pursuant to this paragraph and paragraph
one of this subsection shall not be subject to annual deductibles or
coinsurance.
(E) Such coverage required pursuant to this paragraph and paragraph
one of this subsection shall not restrict or eliminate existing coverage
provided by the contract.
(3) In addition to paragraph one or two of this subsection, every
contract that provides hospital, surgical or medical care coverage,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following preventive care and
screenings for subscribers, and such coverage shall not be subject to
annual deductibles or coinsurance:
(A) evidence-based items or services for preventive care and
screenings that have in effect a rating of 'A' or 'B' in the current
recommendations of the United States preventive services task force;
(B) 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;
(C) 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
(D) with respect to women, such additional preventive care and
screenings not described in subparagraph (A) of this paragraph and as
provided for in comprehensive guidelines supported by the health
resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(k)(1) Every contract 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
contract.
(2) Coverage provided under this subsection 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.
(3) Coverage provided under this subsection 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 contract.
(4) This paragraph 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 corporation's
provider network. Coverage provided under this subsection shall not be
subject to preauthorization. Coverage provided under this subsection
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 corporation 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 corporation 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 corporation 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 corporation 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 corporation which is designated by the office of
alcoholism and substance abuse services. Prior to discharge, the
facility shall indicate to the corporation whether services included in
the discharge plan are secured or determined to be reasonably available.
Any utilization review of treatment provided under this paragraph 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 corporation
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 corporation 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 paragraph other than any copayment,
coinsurance, or deductible otherwise required under the contract.
(5) The criteria for medical necessity determinations under the
contract with respect to inpatient substance use disorder benefits shall
be made available by the corporation to any insured, prospective insured
or in-network provider upon request.
(6) For purposes of this subsection:
(A) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement;
(C) "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 contract; and
(D) "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.
(7) A corporation shall provide coverage under this subsection, 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).
(l) (1) Every contract 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 contract.
(2) Coverage under this subsection 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 substance abuse treatment programs and
are similarly licensed, certified or otherwise authorized in the state
in which the facility is located.
(3) Coverage provided under this subsection 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 contract.
(3-a) A contract that provides large group coverage under this
subsection shall not impose copayments or coinsurance for outpatient
substance use disorder services that exceed 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.
(4) A contract providing coverage for substance use disorder services
pursuant to this subsection shall provide up to twenty outpatient visits
per contract 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 contract pursuant to this subsection. The
coverage required by this subsection shall include treatment as a family
member pursuant to such family member's own contract provided such
family member:
(A) does not exceed the allowable number of family visits provided by
the applicable contract pursuant to this subsection; and
(B) is otherwise entitled to coverage pursuant to this subsection and
such family member's applicable contract.
(5) This paragraph 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 corporation's provider network. Coverage provided
under this subsection shall not be subject to preauthorization. Coverage
provided under this subsection 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 corporation 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
corporation 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 corporation 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 paragraph 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 corporation 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 corporation which is designated by the office of
alcoholism and substance abuse services. A subscriber shall not have any
financial obligation to the facility for any treatment under this
paragraph other than any copayment, coinsurance, or deductible otherwise
required under the contract.
(6) The criteria for medical necessity determinations under the
contract with respect to outpatient substance use disorder benefits
shall be made available by the corporation to any insured, prospective
insured, or in-network provider upon request.
(7) For purposes of this subsection:
(A) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement.
(C) "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 contract; and
(D) "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.
(8) A corporation shall provide coverage under this subsection, 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).
(9) This paragraph 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 corporation's provider network. Benefits for
care in a crisis stabilization center shall not be subject to
preauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or
deductible otherwise required under the contract.
(l-1) (A) No contract that provides medical, major medical or similar
comprehensive-type individual or small group coverage and provides
coverage for prescription drugs for medication for the treatment of a
substance use disorder shall require prior authorization for an initial
or renewal prescription for the detoxification or maintenance treatment
of a substance use disorder, including all buprenorphine products,
methadone, long acting injectable naltrexone, or medication for opioid
overdose reversal prescribed or dispensed to an insured covered under
the contract, including federal food and drug administration-approved
over-the-counter opioid overdose reversal medication as prescribed,
dispensed or as otherwise authorized under state or federal law, except
where otherwise prohibited by law. Every contract that provides medical,
major medical, or similar comprehensive-type large group coverage shall
provide coverage for prescription drugs for medication for the treatment
of a substance use disorder and shall not require prior authorization
for an initial or renewal prescription for the detoxification of
maintenance treatment of a substance use disorder, including all
buprenorphine products, methadone, long acting injectable naltrexone, or
medication for opioid overdose reversal prescribed or dispensed to an
individual covered under the contract, including federal food and drug
administration-approved over-the-counter opioid overdose reversal
medication as prescribed, dispensed or as otherwise authorized under
state or federal law, except where otherwise prohibited by law.
(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.
(l-2) Every policy that provides coverage for treatment at an opioid
treatment program shall not impose a co-payment fee during the course of
treatment on any insured for such treatment. For the purposes of this
section "opioid treatment program" means a program or practitioner
engaged in opioid treatment of individuals with an opioid agonist
treatment medication.
(m) A medical expense indemnity corporation or a health service
corporation which 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 all subscribers in a group
remittance group, or by a contract holder in the case of a group
contract issued pursuant to section four thousand three hundred five of
this chapter, provide reimbursement for such services when performed by
a duly licensed registered professional nurse provided, however, that
reimbursement shall not be made for nursing services provided to a
subscriber 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 group remitting agent or group
contract holder prior to inception of such contract 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.
(n) Every health service or medical expense indemnity corporation
issuing a group contract pursuant to this section or a group remittance
contract for delivery in this state which contract provides
reimbursement to subscribers or physicians, psychiatrists or
psychologists for psychiatric or psychological services or for the
diagnosis and treatment of mental health conditions, however defined in
such contract, must provide the same coverage to persons covered under
the group contract 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 and a mental health counselor, marriage and family
therapist, or psychoanalyst licensed pursuant to article one hundred
sixty-three of the education law. Nothing herein shall be construed to
modify or expand the scope of practice of a mental health counselor,
marriage and family therapist, or psychoanalyst licensed pursuant to
article one hundred sixty-three of the education law. Further, nothing
herein shall be construed to create a new mandated health benefit. The
state board for social work shall maintain a list of all licensed
clinical social workers qualified for reimbursement under this
subsection. The state board for mental health practitioners shall
maintain a list of all licensed mental health counselors, marriage and
family therapists, or psychoanalysts qualified for reimbursement under
this subsection.
(o) A hospital service corporation or a health service corporation
which provides coverage for inpatient hospital care must make available
and, if requested by all persons holding individual contracts in a group
whose premiums are paid by a remitting agent or by the contractholder in
the case of a group contract issued pursuant to section four thousand
three hundred five of this article, provide coverage for hospice care.
For the purposes of this subsection, 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. Hospice care coverage shall be at least equal
to: (1) 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 (2) five
visits for bereavement counseling services, either before or after the
insured's death, provided to the family of the terminally ill insured.
Such coverage shall be made available at the inception of all new
contracts and, with respect to contracts 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. 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 contract period. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract 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.
(p) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides coverage for
hospital, surgical or medical care shall provide the following coverage
for mammography screening for occult breast cancer:
(A) upon the recommendation of a physician, a mammogram, 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;
(B) a single baseline mammogram, which may be provided by breast
tomosynthesis, for covered persons aged thirty-five through thirty-nine,
inclusive;
(C) an annual mammogram, which may be provided by breast tomosythesis,
for covered persons aged forty and older;
(D) for large group contracts offered by a medical expense indemnity
corporation, a hospital service corporation or a health service
corporation 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 corporation's determination that the mammogram is medically
necessary; and
(E) The coverage required in this paragraph or paragraph two of this
subsection shall not be subject to annual deductibles or coinsurance.
(2) For purposes of paragraph one of this subsection, mammography
screening means an X-ray examination of the breast using dedicated
equipment, including X-ray tube, filter, compression device, screens,
films and cassettes, with an average glandular radiation dose less than
0.5 rem per view per breast; provided, however, that mammography
screening shall also include breast tomosythesis.
(3) In addition to paragraph one or two of this subsection, every
contract that provides coverage for hospital, surgical or medical care,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following mammography
screening services, and such coverage shall not be subject to annual
deductibles or coinsurance:
(A) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for mammography not described in subparagraph (A) of this
paragraph and as provided for in comprehensive guidelines supported by
the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(5) Screening and diagnostic imaging for the detection of breast
cancer, including diagnostic mammograms, breast ultrasounds, or magnetic
resonance imaging, covered under the contract shall not be subject to
annual deductibles or coinsurance.
(q) (1) Every policy issued by a medical expense indemnity
corporation, a hospital service corporation or a health service
corporation 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.
(2) Notwithstanding the provisions of this subsection, 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 subsection 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.
(q-1) (1) Every contract issued by a medical expense indemnity
corporation, a hospital service corporation or a health service
corporation for delivery in this state that provides medical, major
medical or similar comprehensive-type coverage and provides coverage for
prescription drugs and 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.
(2) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(A) vary the terms of the contract for the purpose or with the effect
of avoiding compliance with this paragraph;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(C) 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;
(D) 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
(E) achieve compliance with this paragraph by imposing an increase in
cost sharing for an intravenous or injected anticancer medication.
(r) Consistent with federal law, a hospital service corporation or a
health service corporation 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 a person
holding a direct payment individual contract or by all persons holding
individual contracts in a group whose premiums are paid by a remitting
agent or by a contract holder in the case of a group contract issued
pursuant to section four thousand three hundred five of this article,
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 when 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 contracts and, with respect to all
other contracts at each anniversary date of the contract.
(1) Coverage shall be subject to a copayment of twenty-five dollars
per day.
(2) Brochures describing such coverage must be provided at the time of
application for all new contracts and thereafter on each anniversary
date of the contract, and with respect to all other contracts annually
at each anniversary date of the contract. Such brochures must be
approved by the superintendent in consultation with the commissioner of
health.
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.
(3) The commensurate rate for the coverage must be approved by the
superintendent.
* (s) (1) A hospital service corporation or health service corporation
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:
(A) subject to the provisions of paragraph three of this subsection,
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
(B) provided, further however, that subject to the provisions of
paragraph three of this subsection, 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 subsection,
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
(C) 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 paragraph three of this subsection.
(2) A medical expense indemnity or health service corporation 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:
(A) subject to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical or medical procedures
which would correct malformation, disease or dysfunction resulting in
infertility; and
(B) provided, further however, that subject to the provisions of
paragraph three of this subsection, 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 subsection, 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
(C) 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 paragraph three of this subsection.
(3) Coverage of diagnostic and treatment procedures, including
prescription drugs used in the diagnosis and treatment of infertility as
required by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
(A) 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 paragraph.
(B) 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.
(C) Except as provided in subparagraphs (F) and (G) of this paragraph,
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 subparagraph (D) of this paragraph.
(D) 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 paragraph, 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.
(E)(i) For the purposes of this subsection, "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 subsection, "iatrogenic infertility" means
an impairment of fertility by surgery, radiation, chemotherapy or other
medical treatment affecting reproductive organs or processes.
(F) 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 contract.
(G) Every large group contract 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
contract. For purposes of this subparagraph, 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.
(H) No corporation providing coverage under this subsection shall
discriminate based on an insured's expected length of life, present or
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.
(4) Every contract issued by a medical expense indemnity corporation,
a hospital service corporation or a health services corporation 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 corporation has established for the network
participating mail order or other non-retail pharmacy. In such case, the
contract shall not impose any fee, co-payment, co-insurance, deductible
or other condition on any covered person who does not elect to purchase
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 contract that is the result of a collective
bargaining agreement between an employer and a recognized or certified
employee organization.
* NB There are 2 sb (s)'s
* (s) Notwithstanding any provision of a contract issued by a medical
expense indemnity corporation, a dental expense indemnity corporation or
health service corporation, every contract which provides coverage for
care provided through licensed health professionals who can bill for
services shall provide the same coverage and reimbursement for such
service provided pursuant to a clinical practice plan established
pursuant to subdivision fourteen of section two hundred six of the
public health law.
* NB There are 2 sb (s)'s
(t) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides coverage for
hospital, surgical, or medical care shall provide coverage for an annual
cervical cytology screening for cervical cancer and its precursor states
for women aged eighteen and older. Such coverage required by this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given contract.
(2) For purposes of paragraph one of this subsection, cervical
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.
(3) In addition to paragraph one or two of this subsection, every
contract that provides coverage for hospital, surgical or medical care,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following cervical cytology
screening services, and such coverage shall not be subject to annual
deductibles or coinsurance:
(A) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for cervical cytology not described in subparagraph (A) of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(u) (1) A medical expense indemnity corporation or a health service
corporation 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.
(2) 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.
(3) This subsection 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.
(u-1) A medical expense indemnity corporation or a health service
corporation 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 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 subsection 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 four thousand three hundred
six-h of this article.
(v) (1) Every contract issued by a medical expense indemnity
corporation, hospital service corporation or health service corporation
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 after such
covered person has undergone a lymph node dissection or a lumpectomy for
the treatment of breast cancer or a mastectomy covered by the contract.
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
group remitting agent or group contract holder prior to the inception of
such contract and annually thereafter.
(2) A medical expense indemnity corporation, hospital service
corporation or health service corporation which provides coverage under
this subsection and any participating entity through which the insurer
offers health services shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the contract or vary the
terms of the contract for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) 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 subsection;
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection; or
(E) restrict coverage for any portion of a period within a hospital
length of stay required under this subsection in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(3) The prohibitions in paragraph two of this subsection shall be in
addition to the provisions of sections four thousand three hundred
seventeen and four thousand three hundred eighteen of this article and
nothing in this paragraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(w)(1) Every contract issued by a medical expense indemnity
corporation or health service corporation 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 contract that requires, or provides financial
incentives for, the covered person to receive covered services from
health care providers participating in a provider network maintained by
or under contract with the corporation, the contract 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 covered person beyond what such covered
person would have paid for services from a participating appropriate
specialist. Provided however that nothing herein shall impair the
covered person's rights (if any) under the contract 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 contract for services provided by non-participating
providers. The corporation 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 contract that does not provide financial
incentives for, and does not require, the covered person to receive
covered services from health care providers participating in a provider
network maintained by or under contract with the corporation, the
contract shall include coverage for a second medical opinion from a
specialist at no additional cost to the covered person beyond what the
covered person would have paid for comparable services covered under the
contract.
(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
contract and, where applicable, consistent with the provisions of
subparagraphs (i) and (ii) of this paragraph.
Nothing in this subsection shall eliminate or diminish the
corporation's obligation to comply with the provisions of section four
thousand eight hundred four of this chapter and section forty-four
hundred three of the public health law where applicable. Written notice
of the availability of such coverage shall be delivered to the group
remitting agent or group contract holder prior to the inception of such
contract and annually thereafter.
(2) A medical expense indemnity corporation or health service
corporation which provides coverage under this subsection and any
participating entity through which the insurer offers health services
shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the contract or vary the
terms of the contract for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) 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 subsection; or
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection.
(3) The prohibitions in paragraph two of this subsection shall be in
addition to the provisions of sections four thousand three hundred
seventeen and four thousand three hundred eighteen of this article and
nothing in this paragraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(x) (1) Every contract issued by a medical expense indemnity
corporation, hospital service corporation or health service corporation
which provides coverage for surgical or medical care shall provide the
following coverage for breast or chest wall reconstruction surgery after
a mastectomy or partial mastectomy:
(A) all stages of reconstruction of the breast or chest wall on which
the mastectomy or partial mastectomy has been performed; and
(B) surgery and reconstruction of the other breast or chest wall to
produce a symmetrical appearance;
in the manner determined by the attending physician and the patient to
be appropriate. Chest wall reconstruction surgery shall include
aesthetic flat closure as such term is defined by the National Cancer
institute. Such coverage may be subject to annual deductibles or
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 group remitting agent or group
contract holder prior to the inception of such contract and annually
thereafter.
(2) A medical expense indemnity corporation, hospital service
corporation or health service corporation which provides coverage under
this subsection and any participating entity through which the insurer
offers health services shall not:
(A) 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 subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) 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 subsection;
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the affect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection;
(E) restrict coverage for any portion of a period within a hospital
length of stay required under this subsection in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay; or
(F) the prohibitions in this paragraph shall be in addition to the
provisions of sections four thousand three hundred seventeen and four
thousand three hundred eighteen of this article and nothing in this
paragraph shall be construed to suspend, supersede, amend or otherwise
modify such sections.
* (y) Every contract 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 sb§ (y)'s
* (y)(1) Every contract issued by a health service corporation or a
medical expense indemnity corporation which is a "managed care product"
as defined in paragraph four of this subsection that includes coverage
for physician services in a physician's office, and every "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.
(3) Every contract issued by a health service corporation or a medical
expense indemnity corporation which includes coverage for physician
services in a physician's office, and every contract which provides
major medical or similar comprehensive-type coverage, other than a
"managed care product" as defined in paragraph four of this subsection,
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 than those applicable under the same contract 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.
(4) For purposes of this subsection, a "managed care product" shall
mean 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 corporation'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
corporation's managed care provider network, in order for the insured to
be entitled to the maximum reimbursement under the contract.
(5) The coverage required by this subsection shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 sb§ (y)'s
(z) No contract issued by a medical expense indemnity corporation, a
hospital service corporation or a health service corporation shall
exclude coverage of a health care service, as defined in paragraph two
of subsection (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 subsection
shall be provided subject to the terms and conditions generally
applicable to other benefits provided under the policy.
(z-1) (1) 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:
(A) 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
(B) 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.
(2) Such coverage shall not be subject to annual deductibles or
coinsurance.
(aa)(1) Every contract issued by a hospital service company or health
service corporation 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.
(2) 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 subsection, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms of
the policy.
(3) 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.
(4) The provisions of this subsection shall have no application to
transfers of patients between hospitals or health care facilities by an
ambulance service as described in paragraph one of this subsection.
(5) As used in this subsection:
(A) "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 subsection, 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
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.
(B) "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.
(bb) A health service corporation or a medical service expense
indemnity corporation 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 paragraphs
one, two and three of this subsection, 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:
(1) For purposes of paragraphs two and three of this subsection, bone
mineral density measurements or tests, drugs and devices shall include
those covered under the criteria of the federal Medicare program as well
as those in accordance with the criteria of the national institutes of
health, including, as consistent with such criteria, dual-energy x-ray
absorptiometry.
(2) For purposes of paragraphs one and three of this subsection, bone
mineral density measurements or tests, drugs and devices shall be
covered for individuals meeting the criteria for coverage, consistent
with the criteria under the federal Medicare 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.
(3) Such coverage required pursuant to paragraph one or two of this
subsection may be subject to annual deductibles and coinsurance as may
be deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given policy.
(4) In addition to paragraph one, two or three of this subsection,
every contract that provides hospital, surgical or medical care
coverage, except for a grandfathered health plan under paragraph five of
this subsection, shall provide coverage for the following items or
services for bone mineral density, and such coverage shall not be
subject to annual deductibles or coinsurance:
(A) evidence-based items or services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations of
the United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for bone mineral density not described in subparagraph (A) of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(5) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(cc) (1) Every contract 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:
(A) 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:
(i) 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 contract 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 subsection;
(ii) if the covered therapeutic and pharmaceutical equivalent versions
of a drug, device, or product are not available or are deemed medically
inadvisable a contract 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;
(iii) 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
(iv) this coverage must allow for the dispensing of up to twelve
months worth of a contraceptive at one time;
(B) 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;
(C) Patient education and counseling on contraception; and
(D) Follow-up services related to the drugs, devices, products, and
procedures covered under this subsection, including, but not limited to,
management of side effects, counseling for continued adherence, and
device insertion and removal.
(2) A contract subject to this subsection shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this subsection.
(3) Except as otherwise authorized under this subsection, a contract
shall not impose any restrictions or delays on the coverage required
under this subsection.
(4) Benefits for an enrollee under this subsection shall be the same
for an enrollee's covered spouse or domestic partner and covered
nonspouse dependents.
(5) 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.
(A) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:
(i) The inculcation of religious values is the purpose of the entity.
(ii) The entity primarily employs persons who share the religious
tenets of the entity.
(iii) The entity serves primarily persons who share the religious
tenets of the entity.
(iv) 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.
(B) 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.
(6) (A) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
five of this subsection, each enrollee covered under the contract issued
to that group contractholder shall have the right to directly purchase
the rider required by this subsection from the insurer or health
maintenance organization which issued the group contract at the
prevailing small group community rate for such rider whether or not the
employee is part of a small group.
(B) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
five of this subsection, the insurer or health maintenance organization
that provides such coverage shall provide written notice to enrollees
upon enrollment with the insurer or health maintenance organization of
their right to directly purchase a rider for coverage for the cost of
contraceptive drugs or devices. The notice shall also advise the
enrollees of the additional premium for such coverage.
(7) Nothing in this subsection shall be construed as authorizing a
contract which provides coverage for prescription drugs to exclude
coverage for prescription drugs prescribed for reasons other than
contraceptive purposes.
(8) 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.
(dd) No health service corporation or medical service expense
indemnity corporation 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 by such corporation 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.
(ee) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation 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 contract solely because the treatment is provided to
diagnose or treat autism spectrum disorder.
(2) Every contract 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 contract 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 contract. This paragraph shall not be construed as
limiting the benefits that are otherwise available to an individual
under the contract, provided however that such contract 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.
(3) For purposes of this subsection:
(A) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders.
(B) "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.
(C) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided by a person that is 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.
(D) "diagnosis of autism spectrum disorder" means assessments,
evaluations, or tests to diagnose whether an individual has autism
spectrum disorder.
(E) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(F) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist
practices.
(G) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the
psychologist practices.
(H) "therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(I) "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:
(i) behavioral health treatment;
(ii) psychiatric care;
(iii) psychological care;
(iv) medical care provided by a licensed health care provider;
(v) therapeutic care, including therapeutic care which is deemed
habilitative or nonrestorative, in the event that the policy provides
coverage for therapeutic care; and
(vi) pharmacy care in the event that the contract provides coverage
for prescription drugs.
(4) 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.
(5) Nothing in this subsection 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.
(7) Nothing in this subsection shall be construed to prevent a
contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.
(8) Coverage under this subsection 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.
(9) The criteria for medical necessity determinations under the
contract with respect to autism spectrum disorder benefits shall be made
available by the corporation to any insured, prospective insured, or
in-network provider upon request.
(10) For purposes of this subsection:
(A) "financial requirement" means deductible, copayments, coinsurance
and out-of-pocket expenses;
(B) "predominant" means that a financial requirement or treatment
limitation is the most common or frequent of such type of limit or
requirement; and
(C) "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 contract.
(11) A corporation shall provide coverage under this subsection, 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).
(ff) (1) No managed care contract issued by a health service
corporation, hospital service corporation or medical expense indemnity
corporation 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.
(2) No managed care contract issued by a health service corporation,
hospital service corporation or medical expense indemnity corporation
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.
(3) For purposes of this subsection, 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.
(4) For purposes of this subsection, a "managed care contract" is a
contract that requires that services be provided by a provider
participating in the corporation's network in order for the subscriber
to receive the maximum level of reimbursement under the contract.
(gg) (1) Every contract issued by a hospital service corporation,
health service corporation or medical expense indemnity corporation 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:
(A) The out-of-network provider is duly licensed to practice and
authorized to provide such treatment;
(B) The out-of-network provider is located outside the service area of
the insurer;
(C) The in-network healthcare provider treating the covered person for
the condition issues a written order for dialysis treatment stating that
in his or her opinion such treatment is necessary;
(D) The covered person has notified, in writing, the corporation 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 subparagraph (C) of this paragraph. In the
event the covered person must travel on sudden notice due to family or
other emergency, shorter notice may be permitted, provided that the
corporation has reasonable opportunity to review the travel and
treatment plans of the covered person;
(E) The corporation shall have the right to pre-approve the dialysis
treatment and schedule; and
(F) Such coverage is limited to no greater than ten out-of-network
treatments in a calendar year.
(2) Where coverage for out-of-network dialysis treatment is provided
pursuant to paragraph one of this subsection, no corporation 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 corporation shall be the responsibility of the covered person
receiving the out-of-network services.
(3) Such coverage of out-of-network dialysis services required by
paragraph one of this subsection 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.
(hh) 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 subsection,
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.
(ii) Every contract issued by a corporation subject to the provisions
of this article 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.
(jj) No medical expense indemnity corporation, a hospital service
corporation or a health service corporation 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).
(kk) (1) Definitions. For the purpose of this subsection:
(A) "Same reimbursement amount" shall mean that any coverage described
under paragraph two of this subsection shall provide the same benchmark
index, including the same average wholesale price, maximum allowable
cost and national prescription drug codes to reimburse all pharmacies
participating in the health benefit plan regardless of whether a
pharmacy is a mail order pharmacy or a non-mail order pharmacy.
(B) "Mail order pharmacy" means a pharmacy whose primary business is
to receive prescriptions by mail, telefax or through electronic
submissions and to dispense medication to patients through the use of
the United States mail or other common or contract carrier services and
provides any consultation with patients electronically rather than
face-to-face.
(2) Any contract issued by a medical expense indemnity corporation, a
hospital service corporation or a health services corporation that
provides coverage for prescription drugs shall permit each covered
person to fill any covered prescription that may be obtained at a
network participating mail order or other non-retail pharmacy, at the
covered person's option, at a network participating non-mail order
retail pharmacy provided that the network participating non-mail order
retail pharmacy agrees to the same reimbursement amount that the
corporation has established for the network participating mail order or
other non-retail pharmacy. In such a case, the contract shall not impose
a copayment fee or other condition on any covered person who elects to
purchase drugs from a network participating non-mail order retail
pharmacy which is not also imposed on covered persons 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 contract that is the result of a collective
bargaining agreement between an employer and a recognized or certified
employee organization.
(ll) Every small group contract or association group contract issued
by a corporation subject to the provisions of this article 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 four thousand
three hundred six-h of this article;
(2) "grandfathered health plan" means coverage provided by a
corporation in which an individual was enrolled on March twenty-third,
two thousand ten for as long as the coverage maintains grandfathered
status in accordance with section 1251(e) of the affordable care act, 42
U.S.C. § 18011(e); and
(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.
(mm) A corporation shall not be required to offer the contract holder
any benefits that must be made available pursuant to this section if
such benefits must be covered pursuant to subsection (kk) of this
section. For any contract issued within the health benefit exchange
established by this state, a corporation shall not be required to offer
the contract holder any benefits that must be made available pursuant to
this section.
(nn) A corporation 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 which 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.
(oo) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation 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.
(pp) No contract issued by a medical expense indemnity corporation,
hospital service corporation, or health service corporation 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: (1) the registered nurse
first assistant is certified in operating room nursing; (2) the services
are within the scope of practice of a non-physician surgical first
assistant; and (3) the terms and conditions of the contract otherwise
provide for the coverage of the services. Nothing in this subsection
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.
* (qq) Every medical expense indemnity corporation, hospital service
corporation or health service corporation 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.
* NB There are 2 sb§ (qq)'s
* (qq) Whenever in this section a corporation is required to provide
benefits with no coinsurance or deductible, the requirement only applies
with respect to participating providers in the corporation's network, or
with respect to non-participating providers, if the corporation 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 covered person pursuant to
subsection (d) of section four thousand three hundred six-c of this
article, or as applicable, pursuant to paragraph (a) of subdivision six
of section forty-four hundred three of the public health law.
* NB There are 2 sb§ (qq)'s
(rr) Health care forensic examinations performed pursuant to section
twenty-eight hundred five-i of the public health law covered under the
contract shall not be subject to annual deductibles or coinsurance.
(ss)(1) Every policy which provides hospital, surgical, or medical
coverage and which offers maternity care coverage pursuant to subsection
(c) of this section shall also provide coverage for abortion services
for an enrollee.
(2) Coverage for abortion shall not be subject to annual deductibles
or coinsurance, including co-payments, unless the policy is a high
deductible health plan as defined in section 223(c)(2) of the internal
revenue code of 1986, in which case coverage for abortion may be subject
to the plan's annual deductible.
(3) coverage for abortion shall include coverage of any drug
prescribed for the purpose of an abortion, including both generic and
brand name drugs, even if such drug has not been approved by the food
and drug administration for abortion, provided, however, that such drug
shall be a recognized medication for abortion in one of the following
established reference compendia:
(A) The WHO Model Lists of Essential Medicines;
(B) The WHO Abortion Care Guidance; or
(C) The National Academies of Science, Engineering, and Medicine
Consensus Study Report.
(4) Notwithstanding any other provision, a group policy that provides
hospital, surgical, or medical expense coverage delivered or issued for
delivery in this state to a religious employer, as defined in paragraph
five of subsection (cc) of this section, may exclude coverage for
abortion only if the insurer:
(A) obtains an annual certification from the group policy holder that
the policy holder is a religious employer and that the religious
employer requests a contract without coverage for abortion;
(B) issues a rider to each certificate holder at no premium to be
charged to the certificate holder or religious employer for the rider,
that provides coverage for abortions subject to the same rules as would
have been applied to the same category of treatment in the policy issued
to the religious employer. The rider shall clearly and conspicuously
specify that the religious employer does not administer abortion
benefits, but that the insurer is issuing a rider for coverage of
abortion, and shall provide the insurer's contact information for
questions; and
(C) provides notice of the issuance of the policy and rider to the
superintendent in a form and manner acceptable to the superintendent.
* (tt) Every contract issued by a medical expense indemnity
corporation, hospital service corporation, or health service corporation
that provides coverage for a prescription drug shall apply any
third-party payments, financial assistance, discount, voucher or other
price reduction instrument for out-of-pocket expenses made on behalf of
an insured individual for the cost of prescription drugs to the
insured's deductible, copayment, coinsurance, out-of-pocket maximum, or
any other cost-sharing requirement when calculating such insured
individual's overall contribution to any out-of-pocket maximum or any
cost-sharing requirement. If under federal law, application of this
requirement would result in health savings account ineligibility under
26 USC 223, this requirement shall apply for health savings
account-qualified high deductible health plans with respect to the
deductible of such a plan after the enrollee has satisfied the minimum
deductible under 26 USC 223, except for with respect to items or
services that are preventive care pursuant to 26 USC 223(c)(2)(C), in
which case the requirements of this paragraph shall apply regardless of
whether the minimum deductible under 26 USC 223 has been satisfied. This
subsection only applies to a prescription drug that is either (A) a
brand-name drug without an AB rated generic equivalent, as determined by
the United States Food and Drug Administration; or (B) a brand-name drug
with an AB rated generic equivalent, as determined by the United States
Food and Drug Administration, and the insured has access to the
brand-name drug through prior authorization by the insurer or through
the insurer's appeal process, including any step-therapy process; or (C)
a generic drug the insurer will cover, with or without prior
authorization or an appeal process.
* NB There are 2 sb (tt)'s
* (tt) Every large group contract issued by a hospital services
corporation or a health services corporation which provides medical,
major medical, or comprehensive-type coverage shall include coverage for
the cost of pre-exposure prophylaxis (PrEP) for the prevention of HIV
and post-exposure prophylaxis to prevent HIV infection. 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 contract, unless the
pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis has in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force.
* NB There are 2 sb (tt)'s
(uu) (1) Every large group contract 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 large group
contract which provides major medical or similar comprehensive-type
coverage shall provide, upon the prescription of a health care provider
acting within the provider's scope of practice pursuant to title eight
of the education law, coverage for colorectal cancer preventive
screenings in accordance with the American Cancer Society Guidelines for
colorectal cancer screening of average risk individuals. The coverage
required by this subsection shall also include coverage for all
additional colorectal cancer examinations and laboratory tests
recommended in accordance with the American Cancer Society Guidelines
for colorectal cancer screening of average risk individuals, including
an initial colonoscopy or other medical test or procedure for colorectal
cancer screening and a follow-up colonoscopy performed as a result of a
positive result on a non-colonoscopy preventive screening test. A large
group contract shall cover colorectal cancer screenings, examinations,
and laboratory tests described in this subsection upon any contract
issuance or renewal that occurs six months after the date the guideline
described in this subsection is issued.
(2) An enrollee shall not be subject to a deductible, coinsurance, or
any other cost-sharing requirements for services consistent with
paragraph one of this subsection received from participating providers.
Structure New York Laws
Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations
4301 - Organization of Corporation; Purposes; Board of Directors.
4302 - Permit and License to Do Business.
4303-A - Prescription Synchronization.
4306 - Required Contract Provisions.
4306-A - Health Insurance Coverage for Full-Time Students on Medical Leaves of Absence.
4306-B - Primary and Preventive Obstetric and Gynecologic Care.
4306-C - Grievance Procedure and Access to Specialty Care.
4306-D - Choice of Health Care Provider.
4306-E - Prohibition on Lifetime and Annual Limits.
4306-F - Maternal Depression Screenings.
4306-G - Telehealth Delivery of Services.
4306-H - Essential Health Benefits Package and Limit on Cost-Sharing.
4306-I - Coverage for Medically Fragile Children.
4308 - Supervision of Superintendent.
4309 - Limitation on Expenses.
4310 - Investments; Financial Conditions; Reserves.
4312 - Employment of Solicitors; Pension Plans.
4313 - Applicability of Other Provisions of This Chapter.
4314 - Not to Affect Provisions of Workers' Compensation Law.
4315 - Arbitration; Judicial Review.
4316 - Individual Contracts; Premium Refund at Death of Insured.
4317 - Rating of Individual and Small Group Health Insurance Contracts.
4318 - Pre-Existing Condition Provisions.
4318-A - Certification of Creditable Coverage by Corporations Organized Under This Article.
4320 - Limitations on Administrative Services and Stop-Loss Coverage.
4321-A - Fund for Standardized Individual Enrollee Direct Payment Contracts.
4324 - Disclosure of Information.
4326 - Standardized Health Insurance Contracts for Qualifying Small Employers and Individuals.