There is a newer version of the New York Consolidated Laws
2006 New York Code - Group Or Blanket Accident And Health Insurance Policies; Standard Provisions.
§ 3221. Group or blanket accident and health insurance policies;
standard provisions. (a) No policy of group or blanket accident and
health insurance shall, except as provided in subsection (d) hereof, be
delivered or issued for delivery in this state unless it contains in
substance the following provisions or provisions which in the opinion of
the superintendent are more favorable to the holders of such
certificates or not less favorable to the holders of such certificates
and more favorable to policyholders, provided however, that the
provisions set forth in paragraphs six and thirteen of this subsection
shall not be applicable to any such policy which is issued to a
policyholder in accordance with subparagraph (E) of paragraph one of
subsection (c) of section four thousand two hundred thirty-five of this
chapter:
(1) (A) No statement made by the person insured shall avoid the
insurance or reduce benefits thereunder unless contained in a written
instrument signed by the person insured.
(B) All statements contained in any such written instrument shall be
deemed representations and not warranties.
(2) That no agent has authority to change the policy or waive any of
its provisions and that no change in the policy shall be valid unless
approved by an officer of the insurer and evidenced by endorsement on
the policy, or by amendment to the policy signed by the policyholder and
the insurer.
(3) That all new employees or new members in the classes eligible for
insurance must be added to such class for which they are eligible.
(4) That all premiums due under the policy shall be remitted by the
employer or employers of the persons insured or by some other designated
person acting on behalf of the association or group insured, to the
insurer on or before the due date thereof, with such period of grace as
may be specified therein.
(5) The conditions under which the insurer may decline to renew the
policy.
(6) That the insurer shall issue either to the employer or person in
whose name such policy is issued, for delivery to each member of the
insured group, a certificate setting forth in summary form a statement
of the essential features of the insurance coverage and in substance the
following provisions of this subsection.
(7) The ages, to which the insurance provided therein shall be
limited; and the ages, for which additional restrictions are placed on
benefits, and the additional restrictions placed on the benefits at such
ages.
(8) That written notice of claim must be given to the insurer within
twenty days after the occurrence or commencement of any loss covered by
the policy. Failure to give notice within such time shall not invalidate
or reduce any claim if it shall be shown not to have been reasonably
possible to give such notice and that notice was given as soon as was
reasonably possible.
(9) That in the case of claim for loss of time for disability, written
proof of such loss must be furnished to the insurer within thirty days
after the commencement of the period for which the insurer is liable,
and that subsequent written proofs of the continuance of such disability
must be furnished to the insurer at such intervals as the insurer may
reasonably require, and that in the case of claim for any other loss,
written proof of such loss must be furnished to the insurer within
ninety days after the date of such loss. Failure to furnish such proof
within such time shall not invalidate or reduce any claim if it shall be
shown not to have been reasonably possible to furnish such proof within
such time, provided such proof was furnished as soon as reasonably
possible.
(10) That the insurer will furnish to the person making claim or to
the policyholder for delivery to such person such forms as are usually
furnished by it for filing proof of loss. If such forms are not
furnished before the expiration of fifteen days after the insurer
receives notice of any claim under the policy, the person making such
claim shall be deemed to have complied with the requirements of the
policy as to proof of loss upon submitting within the time fixed in the
policy for filing proof of loss, written proof covering the occurrence,
character and extent of the loss for which claim is made.
(11) That the insurer shall have the right and opportunity to examine
the person of the individual for whom claim is made when and so often as
it may reasonably require during the pendency of claim under the policy
and also the right and opportunity to make an autopsy in case of death
where it is not prohibited by law.
(12) That benefits payable under the policy other than benefits for
loss of time will be payable not more than sixty days after receipt of
proof, and that, subject to due proof of loss all accrued benefits
payable under the policy for loss of time will be paid not less
frequently than monthly during the continuance of the period for which
the insurer is liable, and that any balance remaining unpaid at the
termination of such period will be paid immediately upon receipt of such
proof.
(13) That indemnity for loss of life of the insured is payable in
accordance with subsection (e) of section four thousand two hundred
thirty-five of this chapter; and that all other indemnities of the
policy are payable to the insured, except as may be otherwise provided
in accordance with such subsection; and that if a beneficiary is
designated, the consent of the beneficiary shall not be requisite to
change of beneficiary, or to any other changes in the policy or
certificate, except as may be specifically provided by the policy.
(14) That no action at law or in equity shall be brought to recover on
the policy prior to the expiration of sixty days after proof of loss has
been filed in accordance with the requirements of the policy and that no
such action shall be brought after the expiration of two years following
the time such proof of loss is required by the policy.
(15) Any policy and certificate, other than one issued in fulfillment
of the continuing care responsibilities of an operator of a continuing
care retirement community in accordance with article forty-six of the
public health law, made available because of residence in a particular
facility, housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF
A CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE
WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT
COMMUNITY."
(b) No such policy shall be delivered or issued for delivery in this
state unless a schedule of the premium rates pertaining to such form
shall have been filed with the superintendent.
(c) Any portion of any such policy, which purports, by reason of the
circumstances under which a loss is incurred, to reduce any benefits
promised thereunder to an amount less than that provided for the same
loss occurring under ordinary circumstances, shall be printed, in such
policy and in each certificate issued thereunder, in bold face type and
with greater prominence than any other portion of the text of such
policy or certificate; and all other exceptions of the policy shall be
printed in the policy and in the certificate, with the same prominence
as the benefits to which they apply. If any such policy contains any
provision which affects the liability of the insurer, on the grounds
stated in subparagraph (J) or (K) of paragraph two of subsection (d) of
section three thousand two hundred sixteen of this article, then such
provision shall be contained in the policy and certificate in the form
set forth in such section.
(d) (1) The superintendent may approve any form of certificate to be
issued under a blanket accident and health insurance policy as defined
in section four thousand two hundred thirty-seven of this chapter, which
omits or modifies any of the provisions hereinbefore required, if he
deems such omission or modification suitable for the character of such
insurance and not unjust to the persons insured thereunder.
(2) The superintendent may approve any form of group insurance policy
providing disability benefits to be issued pursuant to article nine of
the workers' compensation law which omits or modifies any of the
provisions hereinbefore required, if such omission or modification is
not inconsistent with the provisions of such article nine and he deems
such omission or modification suitable for the character of such
insurance and not unjust to the persons insured thereunder.
(3) The superintendent may also approve any form of group insurance
policy to be issued to a social services district pursuant to
subdivision two of section three hundred sixty-seven-a of the social
services law, which omits or modifies any of the provisions hereinbefore
required, if he deems such omission or modification suitable for the
character of such insurance.
(e) (1) A group policy providing hospital or surgical expense
insurance for other than specific diseases or accident only, shall
provide that if the insurance on an employee or member insured under the
group policy ceases because of termination of (I) employment or of
membership in the class or classes eligible for coverage under the
policy or (II) the policy, for any reason whatsoever, unless the
policyholder has replaced the group policy with similar and continuous
coverage for the same group whether insured or self-insured, such
employee or member who has been insured under the group policy for at
least three months shall be entitled to have issued to him by the
insurer without evidence of insurability upon application made to the
insurer within forty-five days after such termination, and payment of
the quarterly, or, at the option of the employee or member, a less
frequent premium applicable to the class of risk to which the person
belongs, the age of such person, and the form and amount of insurance,
an individual policy of insurance. The insurer may, at its option elect
to provide the insurance coverage under a group insurance policy,
delivered in this state, in lieu of the issuance of a converted
individual policy of insurance. Such individual policy, or group policy,
as the case may be is hereafter referred to as the converted policy. The
benefits provided under the converted policy shall be those required by
subsection (f), (g), (h) or (i) hereof, whichever is applicable and, in
the event of termination of the converted group policy of insurance,
each insured thereunder shall have a right of conversion to a converted
individual policy of insurance.
(2) The insurer shall not be required to issue a converted policy
covering any person if such person is covered for similar benefits by
another hospital or surgical or medical expense insurance policy or
hospital or medical service subscriber contract or medical practice or
other prepayment plan or by any other plan or program or such person is
eligible for similar benefits, whether or not covered therefor, under
any arrangement of coverage for individuals in a group, other than under
the converted policy, whether on an insured or uninsured basis or
similar benefits are provided for or available to such person pursuant
to any statute; and the benefits provided or available under any of such
sources which together with the benefits provided under the converted
policy would result in overinsurance or duplication of benefits
according to standards on file with the superintendent.
(3) The converted policy shall, at the option of the employee or
member, provide identical coverage for the dependents of such employee
or member who were covered under the group policy. Provided, however,
that if the employee or member chooses the option of dependent coverage
then dependents acquired after the permitted time to convert stated in
paragraph one of this subsection shall be added to the converted family
policy in accordance with the provisions of subsection (c) of section
thirty-two hundred sixteen of this article and any regulations
promulgated or guidelines issued by the superintendent. The converted
policy need not provide benefits in excess of those provided for such
persons under the group policy from which conversion is made and may
contain any exclusion or benefit limitation contained in the group
policy or customarily used in individual policies. The effective date of
the individual's coverage under the converted policy shall be the date
of the termination of the individual's insurance under the group policy
as to those persons covered under the group policy.
(4) The converted policy shall not exclude a pre-existing condition
not excluded by the group policy but may provide that any benefits
payable thereunder may be reduced by the amount of any such benefits
payable under the group policy after the termination of the individual's
insurance thereunder, and during the first year of such individual's
coverage under the converted policy the benefits payable under the
policy may be reduced so that they are not in excess of those that would
have been payable had the individual's insurance under the group policy
remained in effect. The converted policy may provide for termination of
coverage thereunder on any person when he is or could be covered by
Medicare (subchapter XVIII of the federal Social Security Act, 42 U.S.C.
§§ 1395 et seq) by reason of age.
(5) If delivery of an individual converted policy is to be made
outside this state, it may be on such form as the insurer may then be
offering for such conversion in the jurisdiction where such delivery is
to be made.
(6) (A) A converted policy may include a provision whereby the
insurer, during the first two years of an individual's coverage under
the policy, may request information in advance of any premium due date
of such policy of any person covered thereunder as to whether he is
covered for similar benefits by another hospital or surgical or medical
expense insurance policy or hospital or medical service subscriber
contract or medical practice or other prepayment plan or by any other
plan or program or similar benefits are provided for, or available to,
such person pursuant to any statute.
(B) If any such person is so covered or such statutory benefits are
provided or available, and such person fails to furnish the insurer the
details of such coverage within thirty-one days after such request, the
benefits payable under the converted policy with respect to such person
may be based on the hospital or surgical or medical expenses actually
incurred after excluding expenses to the extent of the amount of
benefits provided or available therefor from any of the sources referred
to in subparagraph (A) hereof.
(7) The conversion provision shall also be available upon the death of
the employee or member, to the surviving spouse with respect to such of
the spouse and children as are then covered by the group policy, and
shall be available to a child solely with respect to himself upon his
attaining the limiting age of coverage under the group policy while
covered as a dependent thereunder. It shall also be available upon the
divorce or annulment of the marriage of the employee or member, to the
former spouse of such employee or member.
(8) (A) Each certificate holder shall be given written notice of such
conversion privilege and its duration within fifteen days before or
after the date of termination of group coverage, provided that if such
notice be given more than fifteen days but less than ninety days after
the date of termination of group coverage, the time allowed for the
exercise of such privilege of conversion shall be extended for
forty-five days after the giving of such notice. If such notice be not
given within ninety days after the date of termination of group
coverage, the time allowed for the exercise of such conversion privilege
shall expire at the end of such ninety days.
(B) Written notice by the policyholder given to the certificate holder
or mailed to the certificate holder's last known address, or written
notice by the insurer be sent by first class mail to the certificate
holder at the last address furnished to the insurer by the policyholder,
shall be deemed full compliance with the provisions of this subsection
for the giving of notice.
(C) A group contract issued by an insurer may contain a provision to
the effect that notice of such conversion privilege and its duration
shall be given by the policyholder to each certificate holder upon
termination of his group coverage.
(9) This subsection shall not apply to a group policy issued to a
policyholder whose principal activities are located outside this state
by any life insurance company organized and operated without profit to
any private shareholder or individual, and operated exclusively for the
purpose of aiding and strengthening charitable, religious, missionary,
education or philanthropic institutions, by issuing insurance contracts
only to or for the benefit of such institutions, to individuals engaged
in the services of such institutions and to members of the immediate
families of such individuals.
(10) (A) This subsection shall not apply to a group policy insuring
persons employed in an establishment located outside this state and
their dependents issued by a life insurance company which has been
organized for the purpose of establishing a non-profit voluntary
employee beneficiary association to provide life, sickness, accident or
other benefits to eligible employees or their beneficiaries, is operated
exclusively for said purposes and without profit, direct or indirect, to
any private shareholder or individual, and is duly exempt from income
taxation, pursuant to the federal Internal Revenue Code.
(B) Notwithstanding the provisions of subparagraph (A) hereof, any
resident of this state and his dependents who are insured under a group
policy providing hospital or surgical expense insurance for other than
specific diseases or accident only which is issued by a life insurance
company organized as aforementioned, shall be entitled to the conversion
privileges specified in this subsection.
(11) In addition to the right of conversion herein, the employee or
member insured under the policy shall at his option, as an alternative
to conversion, be entitled to have his coverage continued under the
group policy in accordance with the conditions and limitations contained
in subsection (m) of this section, and have issued at the end of the
period of continuation an individual conversion policy subject to the
terms of this subsection. The effective date for the conversion policy
shall be the day following the termination of insurance under the group
policy, or if there is a continuation of coverage, on the day following
the end of the period of continuation. Notwithstanding the foregoing,
the superintendent may require conversion or continuation of insurance
under conditions as set forth in a regulation for insureds under a
policy issued in accordance with subparagraph (E) of paragraph one of
subsection (c) of section four thousand two hundred thirty-five of this
chapter.
(f) Any employee or member who upon becoming entitled to obtain
coverage under a converted policy has attained age sixty, and has been
insured for at least two years under the group policy immediately
preceding the date the employee or member first became entitled to a
converted policy shall have the privilege of obtaining such policy for a
premium computed at a rate which in any policy year shall not exceed one
hundred twenty percent of a net level premium approved by the
superintendent and determined, according to the attained age of the
insured at the time of conversion and the plan of reimbursement elected,
on the basis of current experience of licensed insurers providing such
coverage and of reasonable assumptions as to morbidity, mortality and
interest. Such net level premium may be changed in accordance with
experience and with the approval of the superintendent at intervals of
not more frequently than five years. Notwithstanding the foregoing
provisions of this subsection, nothing herein shall be construed so as
to avoid the requirements of open enrollment and community rating as set
forth elsewhere in this chapter.
(g) The conversion privilege shall, if the group insurance policy
insures the employee or member for basic hospital or surgical expense
insurance, or if the group insurance policy insures the employee or
member for comprehensive medical expense insurance, entitle the employee
or member to obtain coverage under a converted policy providing, at his
option, coverage under any one of the following plans on an expense
incurred basis:
(1) Plan I.
(A) hospital room and board expense benefits of one hundred thirty
dollars per day for a maximum duration of twenty-one days,
(B) miscellaneous hospital expense benefits of a maximum amount of one
thousand three hundred dollars, and
(C) surgical operation expense benefits according to a one thousand
four hundred dollar maximum benefit schedule, or
(2) Plan II.
(A) hospital room and board expense benefits of two hundred thirty
dollars per day for a maximum duration of thirty days,
(B) miscellaneous hospital expense benefits of a maximum amount of two
thousand three hundred dollars, and
(C) surgical operation expense benefits according to a two thousand
four hundred dollar maximum benefit schedule, or
(3) Plan III.
(A) hospital room and board expense benefits of three hundred thirty
dollars a day for a maximum duration of seventy days,
(B) miscellaneous hospital benefits of a maximum amount of three
thousand three hundred dollars, and
(C) surgical operation expense benefits according to a three thousand
five hundred dollar maximum benefit schedule.
(h) The conversion privilege shall, if the group insurance policy
insures the employee or member for major medical expense insurance, or
if the group insurance policy insures the employee or member for
comprehensive medical expense insurance, entitle the employee or member
to obtain coverage under a converted policy providing major medical
coverage under one of the following plans or one at least as favorable
to the covered persons:
(1) A maximum conforming to subparagraph (A) or (B) hereof:
(A) A maximum payment of two hundred thousand dollars for all covered
medical expenses combined during the covered person's lifetime, with an
annual restoration on each January first while coverage is in force, up
to five thousand dollars of the amount counted against the maximum
benefit and not previously restored.
(B) A maximum payment of two hundred thousand dollars for each
unrelated injury or sickness.
(2) Payment of benefits up to eighty percent of covered medical
expenses which are in excess of the deductible, except that when the
combined deductible and other out-of-pocket covered medical expenses not
reimbursed by any other hospital, surgical or medical insurance policy,
or hospital or medical subscriber contract, or other prepayment plan,
exceed two thousand dollars, then payment of benefits shall be at one
hundred percent of covered medical expenses.
(3) (A) A deductible which is the greater of one thousand dollars and
the benefits deductible.
(B) The term "benefits deductible", as used herein, means the value of
any benefits provided on an expense incurred basis which are provided
with respect to covered medical expenses by any other hospital,
surgical, or medical insurance policy or hospital or medical service
subscriber contract or medical practice or other prepayment plan, or any
other plan or program whether on an insured or uninsured basis, or in
accordance with the requirements of any statute and, if pursuant to
subsection (i) hereof, the converted policy provides both basic hospital
or surgical coverage and major medical coverage, the value of such basic
benefits.
(C) The insurer may require that the deductible be satisfied during a
period of not less than three months.
(4) (A) The benefit period shall be each calendar year when the
maximum payment is determined by subparagraph (A) of paragraph one
hereof or twenty-four months when the maximum payment is determined by
subparagraph (B) of paragraph one hereof.
(B) For the purpose of determining the benefits payable, the term
"covered medical expenses", as used above, is defined as the actual
expense incurred, provided however, for hospital room and board charges
an insurer may limit the maximum major medical benefit payable to the
lesser of the hospital's most common semi-private room and board charge
or three hundred thirty dollars per day and, in the case of surgical
charges, an insurer may limit the maximum major medical benefit payable
to the lesser of seventy-five percent of the prevailing reasonable and
customary charges or the benefit payable pursuant to a four thousand
five hundred dollar maximum benefit schedule.
(i) The conversion privilege shall, if the group insurance policy
insures the employee or member for basic hospital or surgical expense
insurance as well as major medical expense insurance, make available the
plans of benefits set forth in subsections (g) and (h) hereof. At the
option of the insurer, such plans of benefits may be provided under one
policy.
(j) No policy of group or blanket accident and health insurance shall
be issued as excess coverage for volunteer firemen over and above the
coverage provided for pursuant to the volunteer firemen's benefit law
unless such excess policy provides for each of the types of coverages
set forth in subdivision one of section five of such law. Any excess
policy which does not contain such provisions shall be construed as if
such coverages were embodied therein.
(k) (1) (A) Every group policy delivered or issued for delivery in
this state which provides coverage for in-patient hospital care shall
provide coverage for home care to residents in this state, except that
this provision shall not apply to a policy which covers persons employed
in more than one state or the benefit structure of which was the subject
of collective bargaining affecting persons who are employed in more than
one state. Such home care coverage shall be included at the inception of
all new policies and, with respect to all other policies, added at any
anniversary date of the policy subject to evidence of insurability.
(B) Such coverage may be subject to an annual deductible of not more
than fifty dollars for each person covered under the policy and may be
subject to a coinsurance provision which provides for coverage of not
less than seventy-five percent of the reasonable charges for such
services.
(C) Home care means the care and treatment of a covered person who is
under the care of a physician but only if hospitalization or confinement
in a nursing facility as defined in subchapter XVIII of the federal
Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
required if home care was not provided, and the plan covering the home
health service is established and approved in writing by such physician.
(D) Home care shall be provided by an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law and shall consist of one or more of the
following:
(i) Part-time or intermittent home nursing care by or under the
supervision of a registered professional nurse (R.N.).
(ii) Part-time or intermittent home health aide services which consist
primarily of caring for the patient.
(iii) Physical, occupational or speech therapy if provided by the home
health service or agency.
(iv) Medical supplies, drugs and medications prescribed by a
physician, and laboratory services by or on behalf of a certified home
health agency or licensed home care services agency to the extent such
items would have been covered under the contract if the covered person
had been hospitalized or confined in a skilled nursing facility as
defined in subchapter XVIII of the federal Social Security Act, 42
U.S.C. §§ 1395 et seq.
(E) For the purpose of determining the benefits for home care
available to a covered person, each visit by a member of a home care
team shall be considered as one home care visit; the contract may
contain a limitation on the number of home care visits, but not less
than forty such visits in any calendar year or in any continuous period
of twelve months, for each person covered under the contract; four hours
of home health aide service shall be considered as one home care visit.
(2) (A) Every insurer issuing a group policy delivered or issued for
delivery in this state which provides coverage for in-patient hospital
care shall include coverage for preadmission tests performed in hospital
facilities prior to scheduled surgery, except that this provision shall
not apply to a policy which covers persons employed in more than one
state or the benefit structure of which was the subject of collective
bargaining affecting persons who are employed in more than one state.
(B) Such policy shall provide benefits for tests ordered by a
physician which are performed in the out-patient facilities of a
hospital as a planned preliminary to admission of the patient as an
in-patient for surgery in the same hospital, provided that:
(i) tests are necessary for and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed;
(ii) reservations for a hospital bed and for an operating room were
made prior to the performance of the tests;
(iii) the surgery actually takes place within seven days of such
presurgical tests; and
(iv) the patient is physically present at the hospital for the tests.
(3) Every group policy delivered or issued for delivery in this state
which provides coverage for in-patient surgical care shall include
coverage for a second surgical opinion by a qualified physician on the
need for surgery, except that this provision shall not apply to a policy
which covers persons employed in more than one state or the benefit
structure of which was the subject of collective bargaining affecting
persons who are employed in more than one state.
(4) (A) Every group policy delivered or issued for delivery in this
state which provides coverage for inpatient hospital care shall include
coverage for services to treat an emergency condition provided in
hospital facilities, except that this provision shall not apply to a
policy which cover 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) In this paragraph, an "emergency condition" means a medical or
behavioral condition, the onset of which is sudden, that manifests
itself by symptoms of sufficient severity, including severe pain, 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, or (ii) serious impairment to such person's bodily functions;
(iii) serious dysfunction of any bodily organ or part of such person; or
(iv) serious disfigurement of such person.
(5) (A) (i) Every group or blanket policy delivered or issued for
delivery in this state which provides hospital, surgical or medical
coverage shall include coverage for maternity care, including hospital,
surgical or medical care to the same extent that coverage is provided
for illness or disease under the policy. Such maternity care coverage,
other than coverage for perinatal complications, shall include inpatient
hospital coverage for mother and newborn for at least forty-eight hours
after childbirth for any delivery other than a caesarean section, and
for at least ninety-six hours after a caesarean section. Such coverage
for maternity care shall include the services of a midwife licensed
pursuant to article one hundred forty of the education law, practicing
consistent with a written agreement pursuant to section sixty-nine
hundred fifty-one of the education law and affiliated or practicing in
conjunction with a facility licensed pursuant to article twenty-eight of
the public health law, but no insurer shall be required to pay for
duplicative routine services actually provided by both a licensed
midwife and a physician.
(ii) Maternity care coverage shall also include, at minimum, parent
education, assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.
(iii) The mother shall have the option to be discharged earlier than
the time periods established in item (i) of this subparagraph. In such
case, the inpatient hospital coverage must include at least one home
care visit which shall be in addition to, rather than in lieu of, any
home health care coverage available under the policy. The policy must
cover the home care visit, which may be requested at any time within
forty-eight hours of the time of delivery (ninety-six hours in the case
of caesarean section), and shall be delivered within twenty-four hours,
(I) after discharge, or (II) of the time of the mother's request,
whichever is later. Such home care coverage shall be pursuant to the
policy and subject to the provisions of this subparagraph, and not
subject to deductibles, coinsurance or copayments.
(B) Coverage provided under this paragraph for care and treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.
(6) (A) Every group policy issued or delivered in this state which
provides coverage for hospital care shall not exclude coverage for
hospital care for diagnosis and treatment of correctable medical
conditions otherwise covered by the policy solely because the medical
condition results in infertility; provided, however that:
(i) subject to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical or medical procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
(ii) provided, further however, that subject to the provisions of
subparagraph (C) of this paragraph, in no case shall such coverage
exclude diagnostic tests and procedures provided as part of such
hospital care that are necessary to determine infertility or that are
necessary in connection with any surgical or medical treatments or
prescription drug coverage provided pursuant to this paragraph,
including such diagnostic tests and procedures as hysterosalpingogram,
hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post
coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
and
(iii) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.
(B) Every group policy issued or delivered in this state which
provides coverage for surgical and medical care shall not exclude
coverage for surgical and medical care for diagnosis and treatment of
correctable medical conditions otherwise covered by the policy solely
because the medical condition results in infertility; provided, however
that:
(i) subject to the provisions of subparagraph (C) of this paragraph,
in no case shall such coverage exclude surgical or medical procedures
which would correct malformation, disease or dysfunction resulting in
infertility; and
(ii) provided, further however, that subject to the provisions of
subparagraph (C) of this paragraph, in no case shall such coverage
exclude diagnostic tests and procedures that are necessary to determine
infertility or that are necessary in connection with any surgical or
medical treatments or prescription drug coverage provided pursuant to
this paragraph, including such diagnostic tests and procedures as
hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,
sono-hysterogram, post coital tests, testis biopsy, semen analysis,
blood tests and ultrasound; and
(iii) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with subparagraph (C) of this paragraph.
(C) Coverage of diagnostic and treatment procedures, including
prescription drugs, used in the diagnosis and treatment of infertility
as required by subparagraphs (A) and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.
(i) Coverage shall be provided for persons whose ages range from
twenty-one through forty-four years, provided that nothing herein shall
preclude the provision of coverage to persons whose age is below or
above such range.
(ii) Diagnosis and treatment of infertility shall be prescribed as
part of a physician's overall plan of care and consistent with the
guidelines for coverage as referenced in this subparagraph.
(iii) 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.
(iv) Coverage shall be limited to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this subparagraph "period of
not less than twelve months" shall be determined by calculating such
time from either the date the insured was first covered under the
existing policy or from the date the insured was first covered by a
previously in-force converted policy, whichever is earlier.
(v) 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 clause (vi) of this subparagraph.
(vi) The superintendent, in consultation with the commissioner of
health, shall promulgate regulations which shall stipulate the
guidelines and standards which shall be used in carrying out the
provisions of this subparagraph, which shall include:
(I) The determination of "infertility" 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 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;
(III) 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
(IV) 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.
(7)(A) Every group or blanket accident and health insurance policy
issued or issued for delivery in this state which provides medical
coverage that includes coverage for physician services in a physician's
office and every policy which provides major medical or similar
comprehensive-type coverage shall include coverage for the following
equipment and supplies for the treatment of diabetes, if recommended or
prescribed by a physician or other licensed health care provider legally
authorized to prescribe under title eight of the education law: blood
glucose monitors and blood glucose monitors for the visually impaired,
data management systems, test strips for glucose monitors and visual
reading and urine testing strips, insulin, injection aids, cartridges
for the visually impaired, syringes, insulin pumps and appurtenances
thereto, insulin infusion devices, and oral agents for controlling blood
sugar. In addition, the commissioner of the department of health shall
provide and periodically update by rule or regulation a list of
additional diabetes equipment and related supplies such as are medically
necessary for the treatment of diabetes, for which there shall also be
coverage. Such policies shall also include coverage for diabetes
self-management education to ensure that persons with diabetes are
educated as to the proper self-management and treatment of their
diabetic condition, including information on proper diets. Such coverage
for self-management education and education relating to diet shall be
limited to visits medically necessary upon the diagnosis of diabetes,
where a physician diagnoses a significant change in the patient's
symptoms or conditions which necessitate changes in a patient's
self-management, or where reeducation or refresher education is
necessary. Such education may be provided by the physician or other
licensed health care provider legally authorized to prescribe under
title eight of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by a certified diabetes
nurse educator, certified nutritionist, certified dietitian or
registered dietitian upon the referral of a physician or other licensed
health care provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified nutritionist, certified dietitian or registered
dietitian may be limited to group settings wherever practicable.
Coverage for self-management education and education relating to diet
shall also include home visits when medically necessary.
(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(C) This paragraph shall not apply to a policy which covers persons
employed in more than one state or the benefit structure of which was
the subject of collective bargaining affecting persons employed in more
than one state unless such policy is issued under the New York state
health insurance plan established under article eleven of the civil
service law or issued to or through a local government.
(8) (A) Every group or blanket policy delivered or issued for delivery
in this state which provides coverage for inpatient hospital care shall
provide such coverage for such period as is determined by the attending
physician in consultation with the patient to be medically appropriate
for such covered person undergoing a lymph node dissection or a
lumpectomy for the treatment of breast cancer or a mastectomy covered by
the policy. Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy. Written notice of the availability of such coverage shall be
delivered to the policyholder prior to inception of such policy and
annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or
(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(9)(A) Every policy which provides medical, major medical, or similar
comprehensive-type coverage must provide coverage for a second medical
opinion by an appropriate specialist, including but not limited to a
specialist affiliated with a specialty care center for the treatment of
cancer, in the event of a positive or negative diagnosis of cancer or a
recurrence of cancer or a recommendation of a course of treatment for
cancer, subject to the following:
(i) In the case of a policy that requires, or provides financial
incentives for, the insured to receive covered services from health care
providers participating in a provider network maintained by or under
contract with the insurer, the policy shall include coverage for a
second medical opinion from a non-participating specialist, including
but not limited to a specialist affiliated with a specialty care center
for the treatment of cancer, when the attending physician provides a
written referral to a non-participating specialist, at no additional
cost to the insured beyond what such insured would have paid for
services from a participating appropriate specialist. Provided, however
that nothing herein shall impair an insured's rights (if any) under the
policy to obtain the second medical opinion from a non-participating
specialist without a written referral, subject to the payment of
additional coinsurance (if any) required by the policy for services
provided by non-participating providers. The insurer shall compensate
the non-participating specialist at the usual, customary and reasonable
rate, or at a rate listed on a fee schedule filed and approved by the
superintendent which provides a comparable level of reimbursement.
(ii) In the case of a policy that does not provide financial
incentives for, and does not require, the insured to receive covered
services from health care providers participating in a provider network
maintained by or under contract with the insurer, the policy shall
include coverage for a second medical opinion from a specialist at no
additional cost to the insured beyond what the insured would have paid
for comparable services covered under the policy.
(iii) Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
policy, and, where applicable, consistent with the provisions of clauses
(i) and (ii) of this subparagraph.
Nothing in this paragraph shall eliminate or diminish an insurer's
obligation to comply with the provisions of section four thousand eight
hundred four of this chapter where applicable. Written notice of the
availability of such coverage shall be delivered to the policyholder
prior to the inception of such policy and annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which an insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph; or
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the coverage provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph.
(C) The prohibitions in subparagraph (B) of this paragraph shall be in
addition to the provisions of sections three thousand two hundred
thirty-one and three thousand two hundred thirty-two of this article and
nothing in this subparagraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(10)(A) Every group or blanket policy delivered or issued for delivery
in this state which provides medical, major medical, or similar
comprehensive-type coverage shall provide the following coverage for
breast reconstruction surgery after a mastectomy:
(i) all stages of reconstruction of the breast on which the mastectomy
has been performed; and
(ii) surgery and reconstruction of the other breast to produce a
symmetrical appearance;
in the manner determined by the attending physician and the patient to
be appropriate. Such coverage may be subject to annual deductibles and
coinsurance provisions as may be deemed appropriate by the
superintendent and as are consistent with those established for other
benefits within a given policy. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such policy and annually thereafter.
(B) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(i) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this paragraph;
(ii) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(iii) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(iv) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or
(v) restrict coverage for any portion of a period within a hospital
length of stay required under this paragraph in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(C) The prohibitions in this paragraph shall be in addition to the
provisions of sections three thousand two hundred thirty-one and three
thousand two hundred thirty-two of this article and nothing in this
paragraph shall be construed to suspend, supersede, amend or otherwise
modify such sections.
* (11) Every policy which provides coverage for prescription drugs
shall include coverage for the cost of enteral formulas for home use 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 for those individuals who are or
will become malnourished or suffer from disorders, which if left
untreated, cause chronic physical disability, mental retardation or
death. Specific diseases 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 with failure to thrive; disorders of gastrointestinal motility
such as chronic intestinal pseudo-obstruction; and multiple, severe food
allergies which if left untreated will cause malnourishment, chronic
physical disability, mental retardation or death. Enteral formulas which
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 shall include
modified solid food products that are low protein or which contain
modified protein which are medically necessary, and such coverage for
such modified solid food products for any calendar year or for any
continuous period of twelve months for any insured individual shall not
exceed two thousand five hundred dollars.
* NB There are 2 par (11)'s
* (11)(A) Every policy which is a "managed care product" as defined in
subparagraph (D) of this paragraph that includes coverage for physician
services in a physician's office, and every policy which is a "managed
care product" that provides major medical or similar comprehensive-type
coverage shall include coverage for chiropractic care, as defined in
section six thousand five hundred fifty-one of the education law,
provided by a doctor of chiropractic licensed pursuant to article one
hundred thirty-two of the education law, in connection with the
detection or correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for the purpose
of removing nerve interference, and the effects thereof, where such
interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column. However, chiropractic care
and services may be subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits, and reasonable
utilization review, provided that any such amounts, limits and review:
(a) shall not function to direct treatment in a manner discriminative
against chiropractic care, and (b) individually and collectively shall
be no more restrictive than those applicable under the same policy to
care or services provided by other health professionals in the
diagnosis, treatment and management of the same or similar conditions,
injuries, complaints, disorders or ailments, even if differing
nomenclature is used to describe the condition, injury, complaint,
disorder or ailment. Nothing herein contained shall be construed as
impeding or preventing either the provision or coverage of chiropractic
care and services by duly licensed doctors of chiropractic, within the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.
(C) Every policy which includes coverage for physician services in a
physician's office, and every policy which provides major medical or
similar comprehensive-type coverage, other than a "managed care product"
as defined in subparagraph (D) of this paragraph, shall provide coverage
for chiropractic care, as defined in section six thousand five hundred
fifty-one of the education law, provided by a doctor of chiropractic
licensed pursuant to article one hundred thirty-two of the education
law, in connection with the detection or correction by manual or
mechanical means of structural imbalance, distortion or subluxation in
the human body for the purpose of removing nerve interference, and the
effects thereof, where such interference is the result of or related to
distortion, misalignment or subluxation of or in the vertebral column.
However, chiropractic care and services may be subject to reasonable
deductible, co-payment and co-insurance amounts, reasonable fee or
benefit limits, and reasonable utilization review, provided that any
such amounts, limits and review: (a) shall not function to direct
treatment in a manner discriminative against chiropractic care, and (b)
individually and collectively shall be no more restrictive that those
applicable under the same policy to care or services provided by other
health professionals in the diagnosis, treatment and management of the
same or similar conditions, injuries, complaints, disorders or ailments,
even if differing nomenclature is used to describe the condition,
injury, complaint, disorder or ailment. Nothing herein contained shall
be construed as impeding or preventing either the provision or coverage
of chiropractic care and services by duly licensed doctors of
chiropractic, within the lawful scope of chiropractic practice, in
hospital facilities on a staff or employee basis.
(D) For purposes of this paragraph, a "managed care product" shall
mean a policy which requires that medical or other health care services
covered under the policy, other than emergency care services, be
provided by, or pursuant to a referral from, a primary care provider,
and that services provided pursuant to such a referral be rendered by a
health care provider participating in the insurer's managed care
provider network. In addition, a managed care product shall also mean
the in-network portion of a contract which requires that medical or
other health care services covered under the contract, other than
emergency care services, be provided by, or pursuant to a referral from,
a primary care provider, and that services provided pursuant to such a
referral be rendered by a health care provider participating in the
insurer's managed care provider network, in order for the insured to be
entitled to the maximum reimbursement under the contract.
(E) The coverage required by this paragraph shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 par (11)'s
(12) No policy of group or blanket accident and health insurance
delivered or issued for delivery in this state shall exclude coverage of
a health care service, as defined in paragraph two of such subdivision
(e) of section four thousand nine hundred of this chapter, rendered or
proposed to be rendered to an insured on the basis that such service is
experimental or investigational, is rendered as part of a clinical trial
as defined in subsection (b-2) of section forty-nine hundred of this
chapter, or a prescribed pharmaceutical product referenced in
subparagraph (B) of paragraph two of subsection (e) of section
forty-nine hundred of this chapter provided that coverage of the patient
costs of such service has been recommended for the insured by an
external appeal agent upon an appeal conducted pursuant to subparagraph
(B) of paragraph four of subsection (b) of section four thousand nine
hundred fourteen of this chapter. The determination of the external
appeal agent shall be binding on the parties. For purposes of this
paragraph, patient costs shall have the same meaning as such term has
for purposes of subparagraph (B) of paragraph four of subsection (b) of
section four thousand nine hundred fourteen of this chapter; provided,
however, that coverage for the services required under this paragraph
shall be provided subject to the terms and conditions generally
applicable to other benefits provided under the policy.
(13) Every group or blanket policy delivered or issued for delivery in
this state which 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 this paragraph, the
insurer or health maintenance organization shall adopt standards which
include the criteria of the federal medicare program and the criteria of
the national institutes of health for the detection of osteoporosis,
provided that such coverage shall be further determined as follows:
(A) for purposes of this paragraph, bone mineral density measurements
or tests, drugs and devices shall include those covered under the
federal Medicare program as well as those in accordance with the
criteria of the national institutes of health, including, as consistent
with such criteria, dual-energy x-ray absorptiometry.
(B) for purposes of this paragraph, bone mineral density measurements
or tests, drugs and devices shall be covered for individuals meeting the
criteria under the federal Medicare program or the criteria of the
national institutes of health; provided that, to the extent consistent
with such criteria, individuals qualifying for coverage shall at a
minimum, include individuals:
(i) previously diagnosed as having osteoporosis or having a family
history of osteoporosis; or
(ii) with symptoms or conditions indicative of the presence, or the
significant risk, of osteoporosis; or
(iii) on a prescribed drug regimen posing a significant risk of
osteoporosis; or
(iv) with lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or
(v) with such age, gender and/or other physiological characteristics
which pose a significant risk for osteoporosis.
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.
(14) No group or blanket policy delivered or issued for delivery in
this state which provides medical, major medical or similar
comprehensive-type coverage shall exclude coverage for services covered
under such policy when provided by a comprehensive care center for
eating disorders pursuant to article twenty-seven-J of the public health
law; provided, however, that reimbursement under such policy for
services provided through such comprehensive care centers shall, to the
extent possible and practicable, be structured in a manner to facilitate
the individualized, comprehensive and integrated plans of care which
such centers' network of practitioners and providers are required to
provide.
(l) (1) Every insurer delivering a group policy or issuing a group
policy for delivery in this state which provides coverage supplementing
part A and part B of subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq, must make available and, if requested by
the policyholder, provide coverage of supplemental home care visits
beyond those provided by part A and part B, sufficient to produce an
aggregate coverage of three hundred sixty-five home care visits per
policy year. Such coverage shall be provided pursuant to regulations
prescribed by the superintendent. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except that this notice
shall not be required where a policy covers two hundred or more
employees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.
(2) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides coverage for
in-patient hospital care must make available, and if requested by the
policyholder, provide coverage for care in a nursing home. Written
notice of the availability of such coverage shall be delivered to the
policyholder prior to inception of such group policy and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.
(B) Such coverage shall be made available at the inception of all new
policies and, with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.
(C) In this paragraph, care in a nursing home means the continued care
and treatment of a covered person who is under the care of a physician
but only if:
(i) the care is provided in a nursing home as defined in section
twenty-eight hundred one of the public health law or a skilled nursing
facility as defined in subchapter XVIII of the federal Social Security
Act, 42 U.S.C. §§ 1395 et seq;
(ii) the covered person has been in a hospital for at least three days
immediately preceding admittance to the nursing home or the skilled
nursing facility; and
(iii) further hospitalization would otherwise be necessary.
(D) In determining the total days of coverage for nursing home care
the aggregate of the number of covered days of care in a hospital and
the number of covered days of care in a nursing home, with two days of
care in a nursing home equivalent to one day of care in a hospital, need
not exceed the number of covered days of hospital care provided under
the contract in a benefit period.
(E) The level of benefits to be provided for nursing home care must be
reasonably related to the benefits provided for hospital care.
(3) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides coverage for
in-patient hospital care must make available and if requested by the
policyholder provide coverage to residents in this state for ambulatory
care in hospital out-patient facilities, as a hospital is defined in
section twenty-eight hundred one of the public health law, or subchapter
XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq, and
physicians' offices. Written notice of the availability of such coverage
shall be delivered to the policyholder prior to inception of such group
policy and annually thereafter, except that this notice shall not be
required where a policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
(B) In this paragraph:
(i) "Ambulatory care in hospital out-patient facilities" means
services for diagnostic X-rays, laboratory and pathological
examinations, physical and occupational therapy and radiation therapy,
and services and medications used for nonexperimental cancer
chemotherapy and cancer hormone therapy, provided that such services and
medications are related to and necessary for the treatment or diagnosis
of the patient's illness or injury, are ordered by a physician and, in
the case of physical therapy services, are to be furnished in connection
with the same illness for which the patient had been hospitalized or in
connection with surgical care, but in no event need benefits for
physical therapy be provided which commences more than six months after
discharge from a hospital or the date surgical care was rendered, and in
no event need benefits for physical therapy be provided after three
hundred sixty-five days from the date of discharge from a hospital or
the date surgical care was rendered.
(ii) "Ambulatory care in physicians' offices" means services for
diagnostic X-rays, radiation therapy, laboratory and pathological
examinations, and services and medications used for nonexperimental
cancer chemotherapy and cancer hormone therapy, provided that such
services and medications are related to and necessary for the treatment
or diagnosis of the patient's illness or injury, and ordered by a
physician.
(C) Such coverage shall be made available at the inception of all new
policies and, with respect to policies issued before January first,
nineteen hundred eighty-three, at the first annual anniversary date
thereafter, without evidence of insurability and at any subsequent
annual anniversary date subject to evidence of insurability.
(4) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides reimbursement for
psychiatric or psychological services or for the diagnosis and treatment
of mental, nervous or emotional disorders and ailments, however defined
in such policy, by physicians, psychiatrists or psychologists, must make
available and if requested by the policyholder provide the same coverage
to insureds for such services when performed by a licensed clinical
social worker, within the lawful scope of his or her practice, who is
licensed pursuant to article one hundred fifty-four of the education
law. Written notice of the availability of such coverage shall be
delivered to the policyholder prior to inception of such group policy
and annually thereafter, except that this notice shall not be required
where a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(B) The state board for social work shall maintain a list of all
licensed clinical social workers qualified for reimbursement under this
paragraph.
(C) Such coverage shall be made available at the inception of all new
policies and, with respect to all other policies at any subsequent
annual anniversary date of the policy subject to evidence of
insurability.
(D) In addition to the requirements of subparagraph (A) of this
paragraph, every insurer issuing a group policy for delivery in this
state which policy provides reimbursement to insureds for psychiatric or
psychological services or for the diagnosis and treatment of mental,
nervous or emotional disorders and ailments, however defined in such
policy, by physicians, psychiatrists or psychologists, must provide the
same coverage to insureds for such services when performed by a licensed
clinical social worker, within the lawful scope of his or her practice,
who is licensed pursuant to subdivision two of section seven thousand
seven hundred four of the education law and in addition shall have
either (i) three or more additional years experience in psychotherapy,
which for the purposes of this subparagraph shall mean the use of verbal
methods in interpersonal relationships with the intent of assisting a
person or persons to modify attitudes and behavior which are
intellectually, socially or emotionally maladaptive, under supervision,
satisfactory to the state board for social work, in a facility, licensed
or incorporated by an appropriate governmental department, providing
services for diagnosis or treatment of mental, nervous or emotional
disorders or ailments, or (ii) three or more additional years experience
in psychotherapy under the supervision, satisfactory to the state board
for social work, of a psychiatrist, a licensed and registered
psychologist or a licensed clinical social worker qualified for
reimbursement pursuant to subsection (h) of this section, or (iii) a
combination of the experience specified in items (i) and (ii) totaling
three years, satisfactory to the state board for social work. The state
board for social work shall maintain a list of all licensed clinical
social workers qualified for reimbursement under this subparagraph.
(5) (A) Every insurer delivering a group policy or issuing a group
policy for delivery, in this state, which provides coverage for
inpatient hospital care must make available, and if requested by
policyholder provide, coverage for the diagnosis and treatment of
mental, nervous or emotional disorders or ailments, however defined in
such policy, at least equal to the following:
(i) with respect to benefits based upon confinement as an inpatient in
a hospital as defined by subdivision ten of section 1.03 of the mental
hygiene law, such benefits may be limited to not less than thirty days
of active treatment in any calendar year;
(ii) with respect to benefits for outpatient care provided in a
facility issued an operating certificate by the commissioner of mental
hygiene pursuant to the provisions of article thirty-one of the mental
hygiene law, or in a facility operated by the department of mental
hygiene, or by a psychiatrist or psychologist licensed to practice in
this state or a professional corporation or university faculty practice
corporation thereof, such benefits may be limited to not less than seven
hundred dollars in any calendar year.
(B) Such coverage shall be made available at the inception of all new
policies and with respect to all other policies and at any anniversary
date of the policy subject to evidence of insurability. Written notice
of the availability of such coverage shall be delivered to the
policyholder prior to inception of such group policy and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.
(C) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent. Such deductibles and
coinsurance may be consistent with those imposed on other benefits
within a given policy.
(D) In this paragraph, "active treatment" means treatment furnished in
conjunction with inpatient confinement for mental, nervous or emotional
disorders or ailments that meet standards prescribed pursuant to the
regulations of the commissioner of mental hygiene.
(6) (A) Every insurer delivering a group or school blanket policy or
issuing a group or school blanket policy for delivery, in this state,
which provides coverage for inpatient hospital care must make available
and, if requested by the policyholder, provide coverage for the
diagnosis and treatment of chemical abuse and chemical dependence,
however defined in such policy, provided, however, that the term
chemical abuse shall mean and include alcohol and substance abuse and
chemical dependence shall mean and include alcoholism and substance
dependence, however defined in such policy. Written notice of the
availability of such coverage shall be delivered to the policyholder
prior to inception of such group policy and annually thereafter, except
that this notice shall not be required where a policy covers two hundred
or more employees or where the benefit structure was the subject of
collective bargaining affecting persons who are employed in more than
one state.
(B) Such coverage shall be at least equal to the following:
(i) with respect to benefits for detoxification as a consequence of
chemical dependence, inpatient benefits in a hospital or a
detoxification facility may not be limited to less than seven days of
active treatment in any calendar year; and
(ii) with respect to benefits for rehabilitation services, such
benefits may not be limited to less than thirty days of inpatient care
in any calendar year.
(C) Such coverage may be limited to facilities in New York state which
are certified by the office of alcoholism and substance abuse services
and, in other states, to those which are accredited by the joint
commission on accreditation of hospitals as alcoholism, substance abuse
or chemical dependence treatment programs.
(D) Such coverage shall be made available at the inception of all new
policies and with respect to all other policies at any anniversary date
of the policy subject to evidence of insurability.
(E) 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.
Further, each insurer shall report to the superintendent each year the
number of contract holders to whom it has issued policies for the
inpatient treatment of chemical dependence, and the approximate number
of persons covered by such policies.
(F) Such coverage shall not replace, restrict or eliminate existing
coverage provided by the policy.
(7) Every insurer delivering a group or school blanket policy or
issuing a group or school blanket policy for delivery in this state
which provides coverage for inpatient hospital care must provide
coverage for at least sixty outpatient visits in any calendar year for
the diagnosis and treatment of chemical dependence of which up to twenty
may be for family members, except that this provision shall not apply to
a policy which covers persons employed in more than one state or the
benefit structure of which was the subject of collective bargaining
affecting persons who are employed in more than one state. Such coverage
may be limited to facilities in New York state certified by the office
of alcoholism and substance abuse services or licensed by such office as
outpatient clinics or medically supervised ambulatory substance abuse
programs and, in other states, to those which are accredited by the
joint commission on accreditation of hospitals as alcoholism or chemical
dependence treatment programs. 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. Except as otherwise
provided in the applicable policy or contract, no insurer delivering a
group or school blanket policy or issuing a group or school blanket
policy providing coverage for alcoholism or substance abuse services
pursuant to this section shall deny coverage to a family member who
identifies themself as a family member of a person suffering from the
disease of alcoholism, substance abuse or chemical dependency and who
seeks treatment as a family member who is otherwise covered by the
applicable policy or contract pursuant to this section. The coverage
required by this paragraph shall include treatment as a family member
pursuant to such family members' own policy or contract provided such
family member (i) does not exceed the allowable number of family visits
provided by the applicable policy or contract pursuant to this section,
and (ii) is otherwise entitled to coverage pursuant to this section and
such family members' applicable policy or contract.
(8) (A) Every insurer issuing a group policy for delivery in this
state which provides medical, major-medical or similar
comprehensive-type coverage must provide coverage for the provision of
preventive and primary care services.
(B) In this paragraph, preventive and primary care services means the
following services rendered to a dependent child of an insured from the
date of birth through the attainment of nineteen years of age:
(i) an initial hospital check-up and well-child visits scheduled in
accordance with the prevailing clinical standards of a national
association of pediatric physicians designated by the commissioner of
health (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service other than the
limits under state law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or under
the supervision of a physician, or other professional licensed under
article one hundred thirty-nine of the education law whose scope of
practice pursuant to such law includes the authority to provide the
specified services. Coverage shall be provided for such services
rendered in a hospital, as defined in section twenty-eight hundred one
of the public health law, or in an office of a physician or other
professional licensed under article one hundred thirty-nine of the
education law whose scope of practice pursuant to such law includes the
authority to provide the specified services;
(ii) at each visit, services in accordance with the prevailing
clinical standards of such designated association, including a medical
history, a complete physical examination, developmental assessment,
anticipatory guidance, appropriate immunizations and laboratory tests
which tests are ordered at the time of the visit and performed in the
practitioner's office, as authorized by law, or in a clinical
laboratory; and
(iii) necessary immunizations as determined by the superintendent in
consultation with the commissioner of health consisting of at least
adequate dosages of vaccine against diphtheria, pertussis, tetanus,
polio, measles, rubella, mumps, haemophilus influenzae type b and
hepatitis b which meet the standards approved by the United States
public health service for such biological products.
(C) Such coverage shall not be subject to annual deductibles and/or
coinsurance.
(D) Such coverage shall not restrict or eliminate existing coverage
provided by the policy.
(9) Every insurer issuing a group policy for delivery in this state
which policy provides coverage for any service within the lawful scope
of practice of a duly licensed registered professional nurse, must make
available, and if requested by the contract holder, provide
reimbursement for such service when such service is performed by a duly
licensed registered professional nurse provided, however, that
reimbursement shall not be made for nursing services provided to an
insured in a general hospital, nursing home or a facility providing
health related services, as such terms are defined in section
twenty-eight hundred one of the public health law, or in a facility, as
such term is defined in subdivision six of section 1.03 of the mental
hygiene law, or in a physician's office. Such coverage may be subject to
annual deductibles and co-insurance as may be deemed appropriate by the
superintendent and are consistent with those imposed on other benefits
within a given policy. Such coverage shall not replace, restrict or
eliminate existing coverage provided by the policy. Coverage for the
services of a duly licensed registered professional nurse need be
provided only if the nature of the patient's illness or condition
requires nursing care which can appropriately be provided by a person
with the education and professional skill of a registered professional
nurse and the nursing care is necessary in the treatment of the
patient's illness or condition. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except that this notice
shall not be required where a policy covers two hundred or more
employees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.
(10) (A) Every insurer issuing a group policy for delivery in this
state which provides coverage for inpatient hospital care must make
available and if requested by the policyholder provide coverage for
hospice care. Written notice of the availability of such coverage shall
be delivered to the policyholder prior to inception of such group policy
and annually thereafter, except that this notice shall not be required
where a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(B) For the purposes of this paragraph, hospice care shall mean the
care and treatment of a covered person who has been certified by such
person's primary attending physician as having a life expectancy of six
months or less and which is provided by a hospice organization certified
pursuant to article forty of the public health law or under a similar
certification process required by the state in which the hospice
organization is located.
(C) Hospice care coverage shall be at least equal to: (i) a total of
two hundred ten days of coverage beginning with the first day on which
care is provided, for inpatient hospice care in a hospice or in a
hospital and home care and outpatient services provided by the hospice,
including drugs and medical supplies, and (ii) five visits for
bereavement counseling services, either before or after the insured's
death, provided to the family of the terminally ill insured.
(D) Such coverage shall be made available at the inception of all new
policies and, with respect to policies issued before the effective date
of this provision, at the first annual anniversary date thereafter,
without evidence of insurability and at any subsequent annual
anniversary date subject to evidence of insurability.
(E) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and are consistent
with those imposed on other benefits within a given policy period.
(11) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for delivery in this state which provides
coverage for hospital, surgical or medical care shall provide the
following coverage for mammography screening for occult breast cancer:
(i) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or who have a
first degree relative with a prior history of breast cancer;
(ii) a single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive; and
(iii) an annual mammogram for covered persons aged forty and older.
(B) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(C) For purposes of this paragraph, mammography screening means an
X-ray examination of the breast using dedicated equipment, including
X-ray tube, filter, compression device, screens, films and cassettes,
with an average glandular radiation dose less than 0.5 rem per view per
breast.
(11-a) (A) Every policy delivered or issued for delivery in this state
which provides medical coverage that includes coverage for physician
services in a physician's office and every policy which provides major
medical or similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized to prescribe
under title eight of the education law, the following coverage for
diagnostic screening for prostatic cancer:
(i) standard diagnostic testing including, but not limited to, a
digital rectal examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and
(ii) an annual standard diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen
test for men age fifty and over who are asymptomatic and for men age
forty and over with a family history of prostate cancer or other
prostate cancer risk factors.
(B) Such coverage 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.
(12) (A) Every insurer delivering a group or blanket policy or issuing
a group or blanket policy for delivery in this state which provides
coverage for prescribed drugs approved by the food and drug
administration of the United States government for the treatment of
certain types of cancer shall not exclude coverage of any such drug on
the basis that such drug has been prescribed for the treatment of a type
of cancer for which the drug has not been approved by the food and drug
administration. Provided, however, that such drug must be recognized for
treatment of the specific type of cancer for which the drug has been
prescribed in one of the following established reference compendia:
(i) the American Medical Association Drug Evaluations;
(ii) the American Hospital Formulary Service Drug Information; or
(iii) the United States Pharmacopeia Drug Information; or recommended
by review article or editorial comment in a major peer reviewed
professional journal.
(B) Notwithstanding the provisions of this paragraph, coverage shall
not be required for any experimental or investigational drugs or any
drug which the food and drug administration has determined to be
contraindicated for treatment of the specific type of cancer for which
the drug has been prescribed. The provisions of this paragraph shall
apply to cancer drugs only and nothing herein shall be construed to
create, impair, alter, limit, modify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.
(13) Consistent with federal law every insurer delivering a group
policy or issuing a group policy for delivery in this state which
provides coverage supplementing part A and part B of subchapter XVIII of
the federal Social Security Act, 42 USC §§ 1395 et seq., shall make
available and, if requested by the policyholder, provide coverage for at
least ninety days of care in a nursing home as defined in section
twenty-eight hundred one of the public health law, except where such
coverage would duplicate coverage that is available under the
aforementioned subchapter XVIII. Such coverage shall be made available
at the inception of all new policies and, with respect to all other
policies at each anniversary date of the policy.
(A) Coverage shall be subject to a copayment of twenty-five dollars
per day.
(B) Brochures describing such coverage must be provided to the
policyholder at the inception of all new policies and thereafter on each
anniversary date of the policy, and with respect to all other policies
annually at each anniversary date of the policy. Such brochures must be
approved by the superintendent in consultation with the commissioner of
health.
(C) The commensurate rate for the coverage must be approved by the
superintendent.
(D) Such insurers shall report to the superintendent each year the
number of contract holders to whom such insurers have issued such
policies for nursing home coverage and the approximate number of persons
covered by such policies.
(14) (A) Every group or blanket policy delivered or issued for
delivery in this state which provides hospital, surgical or medical
coverage shall provide coverage for an annual cervical cytology
screening for cervical cancer and its precursor states for women aged
eighteen and older.
(B) For purposes of this paragraph, cervical cytology screening shall
include an annual pelvic examination, collection and preparation of a
Pap smear, and laboratory and diagnostic services provided in connection
with examining and evaluating the Pap smear.
(C) Such coverage 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.
(15)(A) Every group or blanket policy delivered or issued for delivery
in this state which provides major medical or similar comprehensive-type
coverage shall include coverage for prehospital emergency medical
services for the treatment of an emergency condition when such services
are provided by an ambulance service issued a certificate to operate
pursuant to section three thousand five of the public health law.
(B) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against an insured for the services provided pursuant to
this paragraph, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms of
the policy.
(C) An insurer shall provide reimbursement for those services
prescribed by this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon rates, an
insurer shall pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.
(D) The provisions of this paragraph shall have no application to
transfers of patients between hospitals or health care facilities by an
ambulance service as described in subparagraph (A) of this paragraph.
(E) As used in this paragraph:
(i) "Prehospital emergency medical services" means the prompt
evaluation and treatment of an emergency medical condition, and/or
non-air-borne transportation of the patient to a hospital, provided
however, where the patient utilizes non-air-borne emergency
transportation pursuant to this paragraph, reimbursement will be based
on whether a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of such
transportation to result in (1) placing the health of the person
affected with such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of such person or others in
serious jeopardy; (2) serious impairment to such person's bodily
functions; (3) serious dysfunction of any bodily organ or part of such
person; or (4) serious disfigurement of such person.
(ii) "Emergency condition" means a medical or behavioral condition,
the onset of which is sudden, that manifests itself by symptoms of
sufficient severity, including severe pain, that a prudent layperson,
possessing an average knowledge of medicine and health, could reasonably
expect the absence of immediate medical attention to result in (1)
placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition placing the
health of such person or others in serious jeopardy; (2) serious
impairment to such person's bodily functions; (3) serious dysfunction of
any bodily organ or part of such person; or (4) serious disfigurement of
such person.
(16) Every group or blanket policy which provides coverage for
prescription drugs shall include coverage for the cost of contraceptive
drugs or devices approved by the federal food and drug administration or
generic equivalents approved as substitutes by such food and drug
administration under the prescription of a health care provider legally
authorized to prescribe under title eight of the education law. The
coverage required by this section shall be included in policies and
certificates only through the addition of a rider.
(A) Notwithstanding any other provision of this subsection, a
religious employer may request a contract without coverage for federal
food and drug administration approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so requested,
such contract shall be provided without coverage for contraceptive
methods. This paragraph shall not be construed to deny an enrollee
coverage of, and timely access to, contraceptive methods.
(1) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:
(a) The inculcation of religious values is the purpose of the entity.
(b) The entity primarily employs persons who share the religious
tenets of the entity.
(c) The entity serves primarily persons who share the religious tenets
of the entity.
(d) The entity is a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(2) Every religious employer that invokes the exemption provided under
this paragraph shall provide written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
(B) (i) Where a group policyholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with
subparagraph (A) of this paragraph each certificateholder covered under
the policy issued to that group policyholder shall have the right to
directly purchase the rider required by this paragraph from the insurer
which issued the group policy at the prevailing small group community
rate for such rider whether or not the employee is part of a small
group.
(ii) Where a group policyholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with
subparagraph (A) of this paragraph, the insurer that provides such
coverage shall provide written notice to certificateholders upon
enrollment with the insurer of their right to directly purchase a rider
for coverage for the cost of contraceptive drugs or devices. The notice
shall also advise the certificateholders of the additional premium for
such coverage.
(C) Nothing in this paragraph shall be construed as authorizing a
group or blanket policy which provides coverage for prescription drugs
to exclude coverage for prescription drugs prescribed for reasons other
than contraceptive purposes.
(D) Such coverage may be subject to reasonable annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other drugs or devices covered
under the policy.
(m) A group policy providing hospital, surgical or medical expense
insurance for other than accident only shall provide that if all or any
portion of the insurance on an employee or member insured under the
policy ceases because of termination of employment or membership in the
class or classes eligible for coverage under the policy, such employee
or member shall be entitled without evidence of insurability upon
application to continue his hospital, surgical or medical expense
insurance for himself or herself and his or her eligible dependents,
subject to all of the group policy's terms and conditions applicable to
those forms of benefits and to the following conditions:
(1) Continuation shall cease on the date which the employee, member or
dependant first becomes, after the date of election: (A) entitled to
coverage under title XVIII of the United States Social Security Act
(Medicare) as amended or superseded; or (B) covered as an employee,
member or dependent by any other insured or uninsured arrangement which
provides hospital, surgical or medical coverage for individuals in a
group which does not contain any exclusion or limitation with respect to
any pre-existing condition of such employee, member or dependent, except
the group insurance policy conversion option of this section shall not
be considered as such an arrangement under which an employee, member or
dependent could become covered.
(2) (A) An employee or member who wishes continuation of coverage must
request such continuation in writing within the sixty day period
following the later of: (i) the date of such termination; or (ii) the
date the employee is sent notice by first class mail of the right of
continuation by the group policyholder.
(B) An employee or member who wishes continuation of coverage under
subparagraph (D) of paragraph four of this subsection must give notice
to the employer or group policyholder within sixty days of the
determination under title II or title XVI of the United States Social
Security Act that such employee or member was disabled at the time of
termination of employment or membership or at any time during the first
sixty days of continuation of coverage.
(3) An employee or member electing continuation must pay to the group
policyholder or his employer, but not more frequently than on a monthly
basis in advance, the amount of the required premium payment, but not
more than one hundred two percent of the group rate for the benefits
being continued under the group policy on the due date of each payment.
The employee's or member's written election of continuation, together
with the first premium payment required to establish premium payment on
a monthly basis in advance, must be given to the policyholder or
employer within sixty days of the date the employee's or member's
benefits would otherwise terminate.
(4) Subject to paragraph one of this subsection, continuation of
benefits under the group policy for any person shall terminate at the
first to occur of the following:
(A) The date eighteen months after the date the employee's or member's
benefits under the policy would otherwise have terminated because of
termination of employment or membership; or
(B) The end of the period for which premium payments were made, if the
employee or member fails to make timely payment of a required premium
payment; or
(C) In the case of an eligible dependent of an employee or member, the
date thirty-six months after the date such person's benefits under the
policy would otherwise have terminated by reason of:
(i) the death of the employee or member;
(ii) the divorce or legal separation of the employee or member from
his or her spouse;
(iii) the employee or member becoming entitled to benefits under title
XVIII of the United States Social Security Act (Medicare); or
(iv) a dependent child ceasing to be a dependent child under the
generally applicable requirements of the policy; or
(D) In the case of an employee or member who is determined, under
title II or title XVI of the Social Security Act, to have been disabled
at the time of termination of employment or membership or at any time
during the first sixty days of continuation of coverage, the date
twenty-nine months after the date the employee's or member's benefits
under the policy would otherwise have terminated because of termination
of employment or membership; provided, however, that if such employee or
member is no longer disabled, the benefits provided in this subparagraph
shall terminate the later of (i) the date provided by subparagraph (A)
of this paragraph, or (ii) the month that begins more than thirty-one
days after the date of the final determination under title II or title
XVI of the United States Social Security Act that the employee or member
is no longer disabled; or
(E) The date on which the group policy is terminated or, in the case
of an employee, the date his employer terminates participation under the
group policy. However, if this clause applies and the coverage ceasing
by reason of such termination is replaced by similar coverage under
another group policy, the following shall apply:
(i) The employee or member shall have the right to become covered
under that other group policy, for the balance of the period that he
would have remained covered under the prior group policy in accordance
with this subparagraph had a termination described in this subparagraph
not occurred, and
(ii) The minimum level of benefits to be provided by the other group
policy shall be the applicable level of benefits of the prior group
policy reduced by any benefits payable under that prior group policy,
and
(iii) The prior group policy shall continue to provide benefits to the
extent of its accrued liabilities and extension of benefits as if the
replacement had not occurred.
(5) A notification of the continuation privilege and the time period
in which to request continuation shall be included in each certificate
of coverage.
(6) This subsection shall not be applicable where a continuation
benefit is available to the employee or member pursuant to Chapter 18 of
the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or
Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et
seq.
(n) In addition to all the rights of conversion and continuation
otherwise provided for herein, employees or members insured under the
policy who are also members of a reserve component of the armed forces
of the United States, including the National Guard, shall be entitled to
have supplementary conversion and continuation rights in certain
circumstances as follows:
(1) If the employee or member insured enters upon active duty as
defined in subsection (o) of this section, and the employer or group
policyholder does not voluntarily maintain coverage for such employee or
member insured, the employee or member insured shall be entitled to have
his or her coverage continued under the group policy in accordance with
the conditions and limitations contained in paragraph seven of this
subsection and have issued at the end of the period of continuation an
individual conversion policy subject to the terms of this subsection.
The effective date for the conversion policy shall be the day following
the termination of insurance under the group policy, or if there is a
continuation of coverage on the day following the end of the period of
continuation.
(2) If the employer or group policyholder does not voluntarily
maintain coverage for the employee or member insured during the period
of active duty, and such employee or member insured does not elect the
supplementary conversion and continuation rights provided for herein,
coverage for such employee or member insured shall be suspended during
the period of active duty.
(3) If the employee or member insured elects the supplementary
continuation right provided for herein or coverage under the group plan
is suspended, and such employee or member insured dies during the period
of active duty, the conversion right provided by this section shall be
available to the surviving spouse and children, and shall be available
to a child solely with respect to himself or herself upon his or her
attaining the limiting age of coverage under the group policy while
covered as a dependent thereunder. It shall also be available upon the
divorce or annulment of the marriage of the employee or member insured,
to the former spouse of such employee or member insured, if such divorce
or annulment occurs during the period of active duty.
(4) If the employee or member insured elects the supplementary
conversion and continuation right provided for herein or coverage under
the group plan is suspended, and such employee or member insured is
either reemployed or restored to participation in the group upon return
to civilian status, he or she shall be entitled to resume participation
in insurance offered by the group pursuant to this section, with no
limitations or conditions imposed as a result of such period of active
duty except as set forth in subparagraphs (A) and (B) herein. The right
of resumption provided for herein shall extend to coverage for the
spouse and dependents of the employee or member insured and shall be in
addition to other existing rights granted pursuant to state and federal
laws and regulations and shall not be deemed to qualify or limit such
rights in any way. No exclusion or waiting period may be imposed in
connection with coverage of a health or physical condition of a person
entitled to such right of resumption, or a health or physical condition
of any other person who is covered by the policy unless:
(A) the condition arose during the period of active duty and the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(B) a waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall the sum of the
waiting periods imposed prior to and subsequent to the period of
suspension exceed the length of the waiting period originally imposed.
(5) If the employee or member insured elects the supplementary
conversion and continuation coverage provided for herein:
(A) when such employee or member insured is either reemployed or
restored to participation in the group, coverage under the supplementary
rights provided for herein shall terminate on the date that coverage is
effective due to resumption of participation in the group.
(B) when such employee or member insured is not reemployed or restored
to participation in the group upon return to civilian status, he or she
shall be entitled to the conversion and continuation rights provided by
subsections (e) and (m) of this section.
(i) To elect an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must apply to the
insurer within thirty-one days of the termination of active duty or
discharge from hospitalization incident to such active duty, which
hospitalization continues for a period of not more than one year. Upon
commencement of coverage under the conversion right provided pursuant to
subsection (e) of this section, coverage under the supplementary
continuation right provided for herein shall terminate.
(ii) To elect continuation of coverage pursuant to subsections (e) and
(m) of this section, the employee or member insured must request such
continuation of the employer within thirty-one days of the termination
of active duty or discharge from hospitalization incident to such active
duty, which hospitalization continues for a period of not more than one
year. Upon commencement of coverage under the continuation right
provided pursuant to subsection (e) of this section, coverage under the
supplementary continuation right provided for herein shall terminate.
The employee or member insured shall be entitled to have issued at the
end of the period of continuation an individual conversion policy.
(6) If coverage under the group plan is suspended during the period of
active duty:
(A) when the employee or member insured returns to participation in
the group plan, coverage under the group plan shall be retroactive to
the date of termination of the period of active duty.
(B) when such employee or member insured is not reemployed or restored
to participation in the group upon return to civilian status, he or she
shall be entitled to the conversion and continuation rights provided by
subsections (e) and (m) of this section.
(i) To elect an individual conversion policy pursuant to subsection
(e) of this section, the employee or member insured must apply to the
insurer within thirty-one days of the termination of active duty or
discharge from hospitalization incident to such active duty, which
hospitalization continues for a period of not more than one year.
(ii) To elect continuation of coverage pursuant to subsections (e) and
(m) of this section, the employee or member insured must request such
continuation of the employer within thirty-one days of the termination
of active duty or discharge from hospitalization incident to such active
duty, which hospitalization continues for a period of not more than one
year. The employee or member insured shall be entitled to have issued at
the end of the period of continuation an individual conversion policy.
(7) A group policy providing hospital, surgical or medical expense
insurance for other than accident only shall provide that if all or any
portion of the insurance on an employee or member insured under the
policy ceases because the employee or member insured is ordered to
active duty as defined in subsection (o) of this section, such employee
or member insured shall be entitled, without evidence of insurability,
upon application to continue his or her hospital, surgical or medical
expense insurance for himself or herself and his or her eligible
dependents, under the supplementary conversion and continuation rights
provided for herein, subject to all of the group policy's terms and
conditions applicable to those forms of benefits and to the following
conditions:
(A) continuation shall not be available for: (i) any person who is
covered, becomes covered or could be covered by title XVIII of the
United States Social Security Act (Medicare) as amended or superseded or
(ii) an employee, member or dependent who is covered, becomes covered or
could become covered as an employee, member or dependent by any other
insured or uninsured arrangement which provides hospital, surgical or
medical coverage for individuals in a group, except that the coverage
available to active duty members of the uniformed services and their
family members shall not be considered a group under the terms of this
subsection, and except that the group insurance policy conversion option
of this section shall not be considered as such an arrangement under
which an employee, member or dependent could become covered.
(B) an employee or member insured who wishes continuation of coverage
pursuant to this subsection must request such continuation in writing
within sixty days of being ordered to active duty.
(C) an employee or member insured electing continuation pursuant to
this subsection must pay to the group policyholder or his or her
employer, but not more frequently than on a monthly basis in advance,
the amount of the required premium payment, but not more than the group
rate for the benefits being continued under the group policy on the due
date of each payment.
(8) The supplementary conversion and continuation rights provided for
herein shall apply to:
(A) policies not covered by Chapter 18 of the Employee Retirement
Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the
Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;
(B) policies covered by Chapter 18 of the Employee Retirement Income
Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public
Health Service Act, 42 U.S.C. section 300bb-1 et seq, when active duty
for reservists and the refusal of an employer to voluntarily maintain
coverage for such period of active duty is not considered a qualifying
event.
(o) To be entitled to the right defined in subsection (n) of this
section a person must be a member of a reserve component of the armed
forces of the United States, including the National Guard, who either:
(A) voluntarily or involuntarily enters upon active duty (other than
for the purpose of determining his or her physical fitness and other
than for training), or
(B) has his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units of the
ready reserve or members of a reserve component to active duty, provided
that such additional active duty is at the request and for the
convenience of the federal government, and
(C) serves no more than four years of active duty.
(p)(1) Except as provided in this section, if an insurer delivers or
issues for delivery in this state a group or blanket policy which
provides hospital, surgical or medical expense coverage for other than
accident only, the insurer must renew or continue in force such coverage
at the option of the policyholder.
(2) An insurer may nonrenew or discontinue coverage under such a group
or blanket policy based only on one or more of the following:
(A) The policyholder or a participating entity has failed to pay
premiums or contributions in accordance with the terms of the policy or
the insurer has not received timely premium payments.
(B) The policyholder or a participating entity has performed an act or
practice that constitutes fraud or made an intentional misrepresentation
of material fact under the terms of the coverage.
(C) The policyholder has failed to comply with a material plan
provision relating to employer contribution or group participation
rules, as permitted under section four thousand two hundred thirty-five
of this chapter.
(D) The insurer is ceasing to offer group or blanket policies in a
market in accordance with paragraph three of this subsection.
(E) The policyholder ceases to meet the requirements for a group under
section four thousand two hundred thirty-five of this chapter or a
participating employer, labor union, association or other entity ceases
membership or participation in the group to which the policy is issued.
Coverage terminated pursuant to this paragraph shall be done uniformly
without regard to any health status-related factor relating to any
covered individual.
(F) In the case of an insurer that offers a group or blanket policy in
a market through a network plan, there is no longer any enrollee in
connection with such plan who lives, resides, or works in the service
area of the insurer (or in the area for which the insurer is authorized
to do business).
(G) Such other reasons as are acceptable to the superintendent and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act.
(3)(A) In any case in which an insurer decides to discontinue offering
a particular class of group or blanket policy of hospital, surgical or
medical expense insurance offered in the small or large group market,
the policy of such class may be discontinued by the insurer in
accordance with this chapter in such market only if:
(i) the insurer provides written notice to each policyholder provided
coverage of this class in such market (and to all participants and
beneficiaries covered under such coverage) of such discontinuance at
least ninety days prior to the date of discontinuance of such coverage;
(ii) the insurer offers to each policyholder provided coverage of this
class in such market, the option to purchase all (or, in the case of the
large group market, any) other hospital, surgical and medical expense
coverage currently being offered by the insurer to a group in such
market; and
(iii) in exercising the option to discontinue coverage of this class
and in offering the option of coverage under item (ii) of this
subparagraph, the insurer acts uniformly without regard to the claims
experience of those policyholders or any health status-related factor
relating to any insureds covered or new insureds who may become eligible
for such coverage.
(B) In any case in which an insurer elects to discontinue offering all
hospital, surgical and medical expense coverage in the small group
market or the large group market, or both markets, in this state, health
insurance coverage may be discontinued by the insurer only if:
(i) the insurer provides written notice to the superintendent and to
each policyholder (and participants and beneficiaries covered under such
coverage) of such discontinuance at least one hundred eighty days prior
to the date of the discontinuance of such coverage;
(ii) all hospital, surgical and medical expense coverage issued or
delivered for issuance in this state in such market (or markets) is
discontinued and coverage under such policies in such market (or
markets) is not renewed; and
(iii) in addition to the notice to the superintendent referred to in
item (i) of this subparagraph, the insurer must provide the
superintendent with a written plan to minimize potential disruption in
the marketplace occasioned by its withdrawal from the market.
(C) In the case of a discontinuance under subparagraph (B) of this
paragraph in a market, the insurer may not provide for the issuance of
any group or blanket policy of hospital, surgical or medical expense
insurance in that market in this state during the five year period
beginning on the date of the discontinuance of the last health insurance
policy not so renewed.
(4) At the time of coverage renewal, an insurer may modify the health
insurance coverage for a group or blanket policy offered to a large or
small group policyholder so long as such modification is consistent with
this chapter and effective on a uniform basis among all small group
policyholders with that policy form.
(5) For purposes of this subsection the term "network plan" shall mean
a health insurance policy under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract either with the insurer or another entity which has contracted
with the insurer.
(q)(1) No insurer delivering or issuing for delivery in this state a
group or blanket policy which provides hospital, surgical or medical
expense coverage shall establish rules for eligibility (including
continued eligibility) of any individual or dependent of the individual
to enroll under the policy based on any of the following health
status-related factors:
(A) Health status.
(B) Medical condition (including both physical and mental illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising out of acts
of domestic violence).
(H) Disability.
(2) For purposes of paragraph one of this subsection, rules for
eligibility include rules defining any applicable waiting periods for
such enrollment.
(3) No insurer may, on the basis of any health status-related factor
in relation to the insured or dependent of the insured, require any
insured (as a condition of enrollment or continued enrollment under the
policy) to pay a premium or contribution which is greater than such
premium for a similarly situated insured enrolled in the plan.
(4) Nothing in this subsection shall require an insurer to issue a
group or blanket policy to a group comprised of fifty-one or more lives
exclusive of spouses and dependents.
(5) Where an eligible insured or dependent of an insured rejects
initial enrollment in a group or blanket policy that provides hospital,
surgical or medical expense insurance, an insurer shall permit an
insured or dependent of an insured to enroll for coverage under the
terms of the policy if each of the following conditions is met:
(A) The insured or dependent was covered under another plan or policy
at the time coverage was initially offered.
(B)(i) Coverage under the other plan or policy was provided in
accordance with continuation required by federal or state law and was
exhausted; or
(ii) Coverage under the other plan or policy was subsequently
terminated as a result of loss of eligibility for one or more of the
following reasons:
(I) termination of employment;
(II) termination of the other plan or policy;
(III) death of the spouse;
(IV) legal separation, divorce, or annulment;
(V) reduction in the number of hours of employment; or
(iii) Policyholder contributions toward the payment of premium for the
other plan or contract were terminated.
(C) Coverage must be applied for within thirty days of termination for
one of the reasons set forth in subparagraph (B) of this paragraph.
(6) With respect to group or blanket policies delivered or issued for
delivery in this state covering between two and fifty employees or
members, the provisions of this subsection shall in no way diminish the
rights of such groups pursuant to section three thousand two hundred
thirty-one of this article.
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