There is a newer version of the New York Consolidated Laws
2012 New York Consolidated Laws
ISC - Insurance
Article 43 - (4301 - 4327) NON-PROFIT MEDICAL AND DENTAL INDEMNITY, OR HEALTH AND HOSPITAL SERVICE CORPORATIONS
4303 - Benefits.
NY Ins L § 4303 (2012) What's This?
§ 4303. Benefits. (a) Every contract issued by a hospital service
corporation or health service corporation which provides coverage for
in-patient hospital care shall also provide coverage:
(1) For preadmission testing performed in hospital facilities prior to
scheduled surgery. A patient who uses the out-patient facilities of a
hospital shall be entitled to benefits for tests ordered by a physician
which are performed as a planned preliminary to admission of the patient
as an in-patient for surgery in the same hospital, provided that:
(A) tests are necessary for and consistent with the diagnosis and
treatment of the condition for which surgery is to be performed,
(B) reservations for a hospital bed and for an operating room shall
have been made prior to the performance of the tests,
(C) surgery actually takes place within seven days of such presurgical
tests, and
(D) the patient is physically present at the hospital for the tests.
(2) (A) For services to treat an emergency condition in hospital
facilities:
(i) without the need for any prior authorization determination;
(ii) regardless of whether the health care provider furnishing such
services is a participating provider with respect to such services;
(iii) if the emergency services are provided by a non-participating
provider, without imposing any administrative requirement or limitation
on coverage that is more restrictive than the requirements or
limitations that apply to emergency services received from participating
providers; and
(iv) if the emergency services are provided by a non-participating
provider, the cost-sharing requirement (expressed as a copayment or
coinsurance) shall be the same requirement that would apply if such
services were provided by a participating provider.
(B) Any requirements of section 2719A(b) of the Public Health Service
Act, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the
requirements of this paragraph with respect to coverage of emergency
services shall be applicable to every contract subject to this
paragraph.
(C) For the purpose of this provision, "emergency condition" means a
medical or behavioral condition that manifests itself by acute symptoms
of sufficient severity, including severe pain, such that a prudent
layperson, possessing an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to result
in (i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition placing the
health of such person or others in serious jeopardy; (ii) serious
impairment to such person's bodily functions; (iii) serious dysfunction
of any bodily organ or part of such person; (iv) serious disfigurement
of such person; or (v) a condition described in clause (i), (ii) or
(iii) of section 1867(e)(1)(A) of the Social Security Act.
(D) For the purpose of this provision, "emergency services" means,
with respect to an emergency condition: (i) a medical screening
examination as required under section 1867 of the Social Security Act,
42 U.S.C. § 1395dd, which is within the capability of the emergency
department of a hospital, including ancillary services routinely
available to the emergency department to evaluate such emergency medical
condition; and (ii) within the capabilities of the staff and facilities
available at the hospital, such further medical examination and
treatment as are required under section 1867 of the Social Security Act,
42 U.S.C. § 1395dd, to stabilize the patient.
(E) For the purpose of this provision, "to stabilize" means, with
respect to an emergency condition, to provide such medical treatment of
the condition as may be necessary to assure, within reasonable medical
probability, that no material deterioration of the condition is likely
to result from or occur during the transfer of the subscriber from a
facility or to deliver a newborn child (including the placenta).
(3) For home care to residents in this state. Such home care coverage
shall be included at the inception of all new contracts and, with
respect to all other contracts, added at any anniversary date of the
contract subject to evidence of insurability. Such coverage may be
subject to an annual deductible of not more than fifty dollars for each
covered person and may be subject to a coinsurance provision which
provides for coverage of not less than seventy-five percent of the
reasonable cost of services for which payment may be made. No such
corporation need provide such coverage to persons eligible for medicare.
(A) Home care shall mean the care and treatment of a covered person
who is under the care of a physician but only if:
(i) hospitalization or confinement in a nursing facility as defined in
subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq,
would otherwise have been required if home care was not provided, and
(ii) the plan covering the home health service is established and
approved in writing by such physician.
(B) Home care shall be provided by an agency possessing a valid
certificate of approval or license issued pursuant to article thirty-six
of the public health law.
(C) Home care shall consist of one or more of the following:
(i) part-time or intermittent home nursing care by or under the
supervision of a registered professional nurse (R.N.),
(ii) part-time or intermittent home health aide services which consist
primarily of caring for the patient,
(iii) physical, occupational or speech therapy if provided by the home
health service or agency, and
(iv) medical supplies, drugs and medications prescribed by a
physician, and laboratory services by or on behalf of a certified home
health agency or licensed home care services agency to the extent such
items would have been covered or provided under the contract if the
covered person had been hospitalized or confined in a skilled nursing
facility as defined in subchapter XVIII of the Social Security Act, 42
U.S.C. § 1395 et seq.
(D) For the purpose of determining the benefits for home care
available to a covered person, each visit by a member of a home care
team shall be considered as one home care visit. The contract may
contain a limitation on the number of home care visits, but not less
than forty such visits in any calendar year or in any continuous period
of twelve months, for each covered person. Four hours of home health
aide service shall be considered as one home care visit. Every contract
issued by a hospital service corporation or health service corporation
which provides coverage supplementing part A and part B of subchapter
XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make
available and, if requested by a subscriber holding a direct payment
contract or by all subscribers in a group remittance group or by the
contract holder in the case of group contracts issued pursuant to
section four thousand three hundred five of this article, provide
coverage of supplemental home care visits beyond those provided by part
A and part B, sufficient to produce an aggregate coverage of three
hundred sixty-five home care visits per contract year. Such coverage
shall be provided pursuant to regulations prescribed by the
superintendent. Written notice of the availability of such coverage
shall be delivered to the group remitting agent or group contract holder
prior to inception of such contract and annually thereafter, except that
this notice shall not be required where a policy covers two hundred or
more employees or where the benefit structure was the subject of
collective bargaining affecting persons who are employed in more than
one state.
The provisions of this subsection shall not apply to a contract issued
pursuant to section four thousand three hundred five of this article
which covers persons employed in more than one state or the benefit
structure of which was the subject of collective bargaining affecting
persons who are employed in more than one state.
(b) Every contract issued by a medical expense indemnity corporation
or a health service corporation which provides coverage for in-patient
surgical care shall include coverage for a second surgical opinion by a
qualified physician on the need for surgery, except that this provision
shall not apply to a contract issued pursuant to section four thousand
three hundred five of this article which covers persons employed in more
than one state or the benefit structure of which was the subject of
collective bargaining affecting persons who are employed in more than
one state.
(c) (1) (A) Every contract issued by a corporation subject to the
provisions of this article which provides hospital service, medical
expense indemnity or both shall provide coverage for maternity care
including hospital, surgical or medical care to the same extent that
hospital service, medical expense indemnity or both are provided for
illness or disease under the contract. Such maternity care coverage,
other than coverage for perinatal complications, shall include inpatient
hospital coverage for mother and for newborn for at least forty-eight
hours after childbirth for any delivery other than a caesarean section,
and for at least ninety-six hours following a caesarean section. Such
coverage for maternity care shall include the services of a midwife
licensed pursuant to article one hundred forty of the education law,
practicing consistent with section sixty-nine hundred fifty-one of the
education law and affiliated or practicing in conjunction with a
facility licensed pursuant to article twenty-eight of the public health
law, but no insurer shall be required to pay for duplicative routine
services actually provided by both a licensed midwife and a physician.
(B) Maternity care coverage also shall include, at minimum, parent
education, assistance and training in breast or bottle feeding, and the
performance of any necessary maternal and newborn clinical assessments.
(C) The mother shall have the option to be discharged earlier than the
time periods established in subparagraph (A) of this paragraph. In such
case, the inpatient hospital coverage must include at least one home
care visit, which shall be in addition to, rather than in lieu of, any
home health care coverage available under the contract. The contract
must cover the home care visit which may be requested at any time within
forty-eight hours of the time of delivery (ninety-six hours in the case
of caesarean section), and shall be delivered within twenty-four hours,
(i) after discharge, or (ii) of the time of the mother's request,
whichever is later. Such home care coverage shall be pursuant to the
contract and subject to the provisions of this paragraph, and not
subject to deductibles, coinsurance or copayments.
(2) Coverage provided under this subsection for care and treatment
during pregnancy shall include provision for not less than two payments,
at reasonable intervals and for services rendered, for prenatal care and
a separate payment for the delivery and postnatal care provided.
(d) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and, if requested by a person holding a direct payment individual
contract or by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand three
hundred five of this article, provide coverage for care in nursing
homes. Such coverage shall be made available at the inception of all new
contracts and, with respect to all other contracts, at any anniversary
date subject to evidence of insurability. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(2) For the purpose of this subsection, care in nursing homes shall
mean the continued care and treatment of a covered person who is under
the care of a physician but only if (i) the care is provided in a
nursing home as defined in section two thousand eight hundred one of the
public health law or a skilled nursing facility as defined in subchapter
XVIII of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii)
the covered person has been in a hospital for at least three days
immediately preceding admittance to the nursing home or the skilled
nursing facility, and (iii) further hospitalization would otherwise be
necessary. The aggregate of the number of covered days of care in a
hospital and the number of covered days of care in a nursing home, with
two days of care in a nursing home equivalent to one day of care in a
hospital, need not exceed the number of covered days of hospital care
provided under the contract in a benefit period. The level of benefits
to be provided for nursing home care must be reasonably related to the
benefits provided for hospital care.
(e) (1) A hospital service corporation or a health service corporation
which provides coverage for in-patient hospital care must make available
and, if requested by a person holding a direct payment individual
contract or by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand three
hundred five of this article, provide coverage for ambulatory care in
hospital out-patient facilities, as a hospital is defined in section two
thousand eight hundred one of the public health law, or subchapter XVIII
of the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of
the availability of such coverage shall be delivered to the group
remitting agent or group contract holder prior to inception of such
contract and annually thereafter, except that this notice shall not be
required where a policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
(2) For the purpose of this subsection, ambulatory care in hospital
out-patient facilities shall mean services for diagnostic x-rays,
laboratory and pathological examinations, physical and occupational
therapy and radiation therapy, and services and medications used for
nonexperimental cancer chemotherapy and cancer hormone therapy, provided
that such services and medications are (i) related to and necessary for
the treatment or diagnosis of the patient's illness or injury, (ii)
ordered by a physician and (iii) in the case of physical therapy,
services are to be furnished in connection with the same illness for
which the patient had been hospitalized or in connection with surgical
care, but in no event need benefits for physical therapy be provided
which commences more than six months after discharge from a hospital or
the date surgical care was rendered, and in no event need benefits for
physical therapy be provided after three hundred sixty-five days from
the date of discharge from a hospital or the date surgical care was
rendered. Such coverage shall be made available at the inception of all
new contracts and, with respect to all other contracts, at any
anniversary date subject to evidence of insurability.
(f) (1) A medical expense indemnity corporation or a health service
corporation which provides coverage for physicians' services must make
available and, if requested by a person holding an individual direct
payment contract or by all persons holding individual contracts in a
group whose premiums are paid by a remitting agent or by the contract
holder in the case of a group contract issued pursuant to section four
thousand three hundred five of this article, provide coverage for
ambulatory care in physicians' offices. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(2) For the purpose of this subsection, ambulatory care in physicians'
offices shall mean services for diagnostic x-rays, radiation therapy,
laboratory and pathological examinations, and services and medications
used for nonexperimental cancer chemotherapy and cancer hormone therapy,
provided that such services and medications are (i) related to and
necessary for the treatment or diagnosis of the patient's illness or
injury, and (ii) ordered by a physician. Such coverage shall be made
available at the inception of all new contracts and, with respect to all
other contracts at any anniversary date subject to evidence of
insurability.
(g) (1) A hospital service corporation or a health service
corporation, which provides group, group remittance or school blanket
coverage for inpatient hospital care, shall provide as part of its
contract broad-based coverage for the diagnosis and treatment of mental,
nervous or emotional disorders or ailments, however defined in such
contract, at least equal to the coverage provided for other health
conditions and shall include:
(A) benefits for in-patient care in a hospital as defined by
subdivision ten of section 1.03 of the mental hygiene law, which
benefits may be limited to not less than thirty days of active treatment
in any contract year, plan year or calendar year.
(B) benefits for out-patient care provided in a facility issued an
operating certificate by the commissioner of mental health pursuant to
the provisions of article thirty-one of the mental hygiene law or in a
facility operated by the office of mental health, which benefits may be
limited to not less than twenty visits in any contract year, plan year
or calendar year. Benefits for partial hospitalization program services
shall be provided as an offset to covered inpatient days at a ratio of
two partial hospitalization visits to one inpatient day of treatment.
(C) Such coverage may be provided on a contract year, plan year or
calendar year basis and shall be consistent with the provision of other
benefits under the contract. Such coverage may be subject to annual
deductibles, co-pays and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the contract.
(D) For the purpose of this subsection, "active treatment" means
treatment furnished in conjunction with in-patient confinement for
mental, nervous or emotional disorders or ailments that meet such
standards as shall be prescribed pursuant to the regulations of the
commissioner of mental health.
(E) In the event the group remittance group or contract holder is
provided coverage under this subsection and under paragraph one of
subsection (h) of this section from the same health service corporation,
or under a contract that is jointly underwritten by two health service
corporations or by a health service corporation and a medical expense
indemnity corporation, the aggregate of the benefits for outpatient care
obtained under subparagraph (B) of this paragraph and paragraph one of
subsection (h) of this section may be limited to not less than twenty
visits in any contract year, plan year or calendar year.
(2) (A) A hospital service corporation or a health service
corporation, which provides group, group remittance or school blanket
coverage for inpatient hospital care, shall provide comparable coverage
for adults and children with biologically based mental illness. Such
hospital service corporation or health service corporation shall also
provide such comparable coverage for children with serious emotional
disturbances. Such coverage shall be provided under the terms and
conditions otherwise applicable under the contract, including network
limitations or variations, exclusions, co-pays, coinsurance, deductibles
or other specific cost sharing mechanisms. Provided further, where a
contract provides both in-network and out-of-network benefits, the
out-of-network benefits may have different coinsurance, co-pays, or
deductibles, than the in-network benefits, regardless of whether the
contract is written under one license or two licenses.
(B) For purposes of this subsection, the term "biologically based
mental illness" means a mental, nervous, or emotional condition that is
caused by a biological disorder of the brain and results in a clinically
significant, psychological syndrome or pattern that substantially limits
the functioning of the person with the illness. Such biologically based
mental illnesses are defined as schizophrenia/psychotic disorders, major
depression, bipolar disorder, delusional disorders, panic disorder,
obsessive compulsive disorders, anorexia, and bulimia.
(3) For purposes of this subsection, the term "children with serious
emotional disturbances" means persons under the age of eighteen years
who have diagnoses of attention deficit disorders, disruptive behavior
disorders, or pervasive development disorders, and where there are one
or more of the following:
(A) serious suicidal symptoms or other life-threatening
self-destructive behaviors;
(B) significant psychotic symptoms (hallucinations, delusion, bizarre
behaviors);
(C) behavior caused by emotional disturbances that placed the child at
risk of causing personal injury or significant property damage; or
(D) behavior caused by emotional disturbances that placed the child at
substantial risk of removal from the household.
(4) (A) The provisions of paragraph two of this subsection shall not
apply to any group remittance group or group contract holder with fifty
or fewer employees who is a group remittance group or group contract
holder of a policy that is subject to the provisions of this section;
provided however that a hospital service corporation or health service
corporation must make available, and if requested by such group
remitting agent or group contract holder, provide the coverage as
specified in paragraph two of this subsection. Written notice of the
availability of such coverage shall be delivered to the remitting agent
or group contract holder prior to inception of such contract and
annually thereafter.
(B) The superintendent shall develop and implement a methodology to
cover the cost to any such group contract holder for providing the
coverage required in paragraph one of this subsection. Such methodology
shall be financed from moneys appropriated from the General Fund that
shall be made available to the superintendent for such purposes, to the
extent of funds available.
(5)(A) Nothing in this subsection shall be construed to prevent the
medical management or utilization review of mental health benefits,
including the use of prospective, concurrent or retrospective
utilization review, preauthorization, and appropriateness criteria as to
the level and intensity of treatment applicable to behavioral health.
(B) Nothing in this subsection shall be construed to prevent a
contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.
(C) Nothing in this subsection shall be construed to require a
contract: (I) to cover mental health benefits or services for
individuals who are presently incarcerated, confined or committed to a
local correctional facility or a prison, or a custodial facility for
youth operated by the office of children and family services; or (II) to
cover services solely because such services are ordered by a court.
(D) Nothing in this subsection shall be deemed to require a contract
to cover benefits or services deemed cosmetic in nature on the grounds
that changing or improving an individual's appearance is justified by
the individual's mental health needs.
(h) (1) A medical expense indemnity corporation or a health service
corporation, which provides group, group remittance or school blanket
coverage for physician services, shall provide as part of its contract
broad-based coverage for the diagnosis and treatment of mental, nervous
or emotional disorders or ailments, however defined in such contract, at
least equal to the coverage provided for other health conditions and
shall include: benefits for outpatient care provided by a psychiatrist
or psychologist licensed to practice in this state, a licensed clinical
social worker who meets the requirements of subsection (n) of this
section, or a professional corporation or university faculty practice
corporation thereof, which benefits may be limited to not less than
twenty visits in any contract year, plan year or calendar year. Such
coverage may be provided on a contract year, plan year or calendar year
basis and shall be consistent with the provision of other benefits under
the contract. Such coverage may be subject to annual deductibles,
co-pays and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the contract. In the event the group remittance group or
contract holder is provided coverage provided under this paragraph and
under subparagraph (B) of paragraph one of subsection (g) of this
section from the same health service corporation, or under a contract
which is jointly underwritten by two health service corporations or by a
health service corporation and a medical expense indemnity corporation,
the aggregate of the benefits for out-patient care obtained under
subparagraph (B) of paragraph one of subsection (g) of this section and
this paragraph may be limited to not less than twenty visits in any
contract year, plan year or calendar year.
(2) (A) A medical expense indemnity corporation or a health service
corporation, which provides group, group remittance or school blanket
coverage for physician services, shall provide comparable coverage for
adults and children with biologically based mental illness. Such medical
expense indemnity corporation or health service corporation shall also
provide such comparable coverage for children with serious emotional
disturbances. Such coverage shall be provided under the terms and
conditions otherwise applicable under the contract, including network
limitations or variations, exclusions, co-pays, coinsurance, deductibles
or other specific cost sharing mechanisms. Provided further, where a
contract provides both in-network and out-of-network benefits, the
out-of-network benefits may have different coinsurance, co-pays, or
deductibles, than the in-network benefits, regardless of whether the
contract is written under one license or two licenses.
(B) For purposes of this subsection, the term "biologically based
mental illness" means a mental, nervous, or emotional condition that is
caused by a biological disorder of the brain and results in a clinically
significant, psychological syndrome or pattern that substantially limits
the functioning of the person with the illness. Such biologically based
mental illnesses are defined as schizophrenia/psychotic disorders, major
depression, bipolar disorder, delusional disorders, panic disorder,
obsessive compulsive disorder, anorexia, and bulimia.
(3) For purposes of this subsection, the term "children with serious
emotional disturbances" means persons under the age of eighteen years
who have diagnoses of attention deficit disorders, disruptive behavior
disorders, or pervasive development disorders, and where there are one
or more of the following:
(A) serious suicidal symptoms or other life-threatening
self-destructive behaviors;
(B) significant psychotic symptoms (hallucinations, delusion, bizarre
behaviors);
(C) behavior caused by emotional disturbances that placed the child at
risk of causing personal injury or significant property damage; or
(D) behavior caused by emotional disturbances that placed the child at
substantial risk of removal from the household.
(4) (A) The provisions of paragraph two of this subsection shall not
apply to any group remittance group or group contract holder with fifty
or fewer employees who is a group remittance group or group contract
holder of a contract that is subject to the provisions of this section;
provided, however, that a hospital service corporation or health service
corporation must make available, and if requested by such group
remitting agent or group contract holder, provide the coverage as
specified in paragraph two of this subsection. Written notice of the
availability of the coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract and
annually thereafter.
(B) The superintendent shall develop and implement a methodology to
cover the cost to any such group remittance group and group contract
holder for providing the coverage required in paragraph one of this
subsection. Such methodology shall be financed from moneys appropriated
from the General Fund that shall be made available to the superintendent
for such purposes, to the extent of funds available.
(5)(A) Nothing in this subsection shall be construed to prevent the
medical management or utilization review of mental health benefits,
including the use of prospective, concurrent or retrospective
utilization review, preauthorization, and appropriateness criteria as to
the level and intensity of treatment applicable to behavioral health.
(B) Nothing in this subsection shall be construed to prevent a
contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.
(C) Nothing in this subsection shall be construed to require a
contract: (I) to cover mental health benefits or services for
individuals who are presently incarcerated, confined or committed to a
local correctional facility or a prison, or a custodial facility for
youth operated by the office of children and family services; or (II) to
cover services solely because such services are ordered by a court.
(D) Nothing in this subsection shall be deemed to require a contract
to cover benefits or services deemed cosmetic in nature on the grounds
that changing or improving an individual's appearance is justified by
the individual's mental health needs.
(i) A medical expense indemnity corporation or health service
corporation which provides coverage for physicians, psychiatrists or
psychologists for psychiatric or psychological services or for the
diagnosis and treatment of mental, nervous or emotional disorders and
ailments, however defined in such contract, must make available and if
requested by all persons holding individual contracts in a group whose
premiums are paid by a remitting agent or by the contract holder in the
case of a group contract issued pursuant to section four thousand three
hundred five of this article, provide the same coverage 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. The state board for social
work shall maintain a list of all licensed clinical social workers
qualified for reimbursement under this subsection. Such coverage shall
be made available at the inception of all new contracts and, with
respect to all other contracts, at any anniversary date subject to
evidence of insurability. Written notice of the availability of such
coverage shall be delivered to the group remitting agent or group
contract holder prior to inception of such contract and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.
(j)(1) A health service corporation or medical expense indemnity
corporation that provides medical, major-medical or similar
comprehensive-type coverage shall provide coverage for the provision of
preventive and primary care services.
(2) For purposes of this paragraph and paragraph one of this
subsection, preventive and primary care services shall mean the
following services rendered to a covered child of a subscriber from the
date of birth through the attainment of nineteen years of age:
(A) an initial hospital check-up and well-child visits scheduled in
accordance with the prevailing clinical standards of a national
association of pediatric physicians designated by the commissioner of
health (except for any standard that would limit the specialty or forum
of licensure of the practitioner providing the service other than the
limits under state law). Coverage for such services rendered shall be
provided only to the extent that such services are provided by or under
the supervision of a physician, or other professional licensed under
article one hundred thirty-nine of the education law whose scope of
practice pursuant to such law includes the authority to provide the
specified services. Coverage shall be provided for such services
rendered in a hospital, as defined in section twenty-eight hundred one
of the public health law, or in an office of a physician or other
professional licensed under article one hundred thirty-nine of the
education law whose scope of practice pursuant to such law includes the
authority to provide the specified services,
(B) at each visit, services in accordance with the prevailing clinical
standards of such designated association, including a medical history, a
complete physical examination, developmental assessment, anticipatory
guidance, appropriate immunizations and laboratory tests which tests are
ordered at the time of the visit and performed in the practitioner's
office, as authorized by law, or in a clinical laboratory, and
(C) necessary immunizations, as determined by the superintendent in
consultation with the commissioner of health, consisting of at least
adequate dosages of vaccine against diphtheria, pertussis, tetanus,
polio, measles, rubella, mumps, haemophilus influenzae type b and
hepatitis b, which meet the standards approved by the United States
public health service for such biological products.
(D) Such coverage required pursuant to this paragraph and paragraph
one of this subsection shall not be subject to annual deductibles or
coinsurance.
(E) Such coverage required pursuant to this paragraph and paragraph
one of this subsection shall not restrict or eliminate existing coverage
provided by the contract.
(3) In addition to paragraph one or two of this subsection, every
contract that provides hospital, surgical or medical care coverage,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following preventive care and
screenings for subscribers, and such coverage shall not be subject to
annual deductibles or coinsurance:
(A) evidence-based items or services for preventive care and
screenings that have in effect a rating of 'A' or 'B' in the current
recommendations of the United States preventive services task force;
(B) immunizations that have in effect a recommendation from the
advisory committee on immunization practices of the centers for disease
control and prevention with respect to the individual involved;
(C) with respect to children, including infants and adolescents,
evidence-informed preventive care and screenings provided for in
comprehensive guidelines supported by the health resources and services
administration; and
(D) with respect to women, such additional preventive care and
screenings not described in subparagraph (A) of this paragraph and as
provided for in comprehensive guidelines supported by the health
resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(k) A hospital service corporation or a health service corporation
which provides group, group remittance or school blanket coverage for
inpatient hospital care must make available and if requested by the
contract holder 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, 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 shall be at least
equal to the following: (1) with respect to benefits for detoxification
as a consequence of chemical dependence, inpatient benefits for care in
a hospital or detoxification facility may not be limited to less than
seven days of active treatment in any calendar year; and (2) with
respect to benefits for inpatient rehabilitation services, such benefits
may not be limited to less than thirty days of inpatient rehabilitation
in a hospital based or free standing chemical dependence facility in any
calendar year. 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. 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
subsection at the first annual anniversary date thereafter, without
evidence of insurability and at any subsequent annual anniversary date
subject to evidence of insurability. Such coverage may be subject to
annual deductibles and 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 hospital service corporation or
health service corporation 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. Such coverage shall not replace,
restrict or eliminate existing coverage provided by the policy. Written
notice of the availability of such coverage shall be delivered to the
group remitting agent or group contract holder prior to inception of
such contract and annually thereafter, except that this notice shall not
be required where a policy covers two hundred or more employees or where
the benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
(l) A hospital service corporation or a health service corporation
which provides group, group remittance or school blanket 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 contract issued pursuant
to section four thousand three hundred five of this article which covers
persons employed in more than one state or the benefit structure of
which was the subject of collective bargaining affecting persons who are
employed in more than one state. 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
substance abuse 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 hospital service
corporation or health service corporation 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 subsection 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.
(m) A medical expense indemnity corporation or a health service
corporation which provides coverage for any service within the lawful
scope of practice of a duly licensed registered professional nurse must
make available, and if requested by all subscribers in a group
remittance group, or by a contract holder in the case of a group
contract issued pursuant to section four thousand three hundred five of
this chapter, provide reimbursement for such services when performed by
a duly licensed registered professional nurse provided, however, that
reimbursement shall not be made for nursing services provided to a
subscriber in a general hospital, nursing home, or a facility providing
health related services, as such terms are defined in section
twenty-eight hundred one of the public health law, or in a facility, as
such term is defined in subdivision six of section 1.03 of the mental
hygiene law, or in a physician's office. Such coverage may be subject to
annual deductibles and co-insurance as may be deemed appropriate by the
superintendent and are consistent with those imposed on other benefits
within a given policy. Such coverage shall not replace, restrict or
eliminate existing coverage provided by the policy. Coverage for the
services of a duly licensed registered professional nurse need be
provided only if the nature of the patient's illness or condition
requires nursing care which can appropriately be provided by a person
with the education and professional skill of a registered professional
nurse and the nursing care is necessary in the treatment of the
patient's illness or condition. Written notice of the availability of
such coverage shall be delivered to the group remitting agent or group
contract holder prior to inception of such contract and annually
thereafter, except that this notice shall not be required where a policy
covers two hundred or more employees or where the benefit structure was
the subject of collective bargaining affecting persons who are employed
in more than one state.
(n) In addition to the requirements of subsection (i) of this section,
every health service or medical expense indemnity corporation issuing a
group contract pursuant to this section or a group remittance contract
for delivery in this state which contract provides reimbursement to
subscribers or physicians, psychiatrists or psychologists for
psychiatric or psychological services or for the diagnosis and treatment
of mental, nervous or emotional disorders and ailments, however defined
in such contract, must provide the same coverage to persons covered
under the group contract for such services when performed by a licensed
clinical social worker, within the lawful scope of his or her practice,
who is licensed pursuant to 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 subsection 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 (i) of this section, or (iii) a
combination of the experience specified in paragraphs (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
subsection.
(o) A hospital service corporation or a health service corporation
which provides coverage for inpatient hospital care must make available
and, if requested by all persons holding individual contracts in a group
whose premiums are paid by a remitting agent or by the contractholder in
the case of a group contract issued pursuant to section four thousand
three hundred five of this article, provide coverage for hospice care.
For the purposes of this subsection, hospice care shall mean the care
and treatment of a covered person who has been certified by such
person's primary attending physician as having a life expectancy of six
months or less and which is provided by a hospice organization certified
pursuant to article forty of the public health law or under a similar
certification process required by the state in which the hospice
organization is located. Hospice care coverage shall be at least equal
to: (1) a total of two hundred ten days of coverage beginning with the
first day on which care is provided, for inpatient hospice care in a
hospice or in a hospital and home care and outpatient services provided
by the hospice, including drugs and medical supplies, and (2) five
visits for bereavement counseling services, either before or after the
insured's death, provided to the family of the terminally ill insured.
Such coverage shall be made available at the inception of all new
contracts and, with respect to contracts issued before the effective
date of this provision, at the first annual anniversary date thereafter,
without evidence of insurability and at any subsequent annual
anniversary date subject to evidence of insurability. Such coverage may
be subject to annual deductibles and coinsurance as may be deemed
appropriate by the superintendent and are consistent with those imposed
on other benefits within a given contract period. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a policy covers two hundred or more employees or where the benefit
structure was the subject of collective bargaining affecting persons who
are employed in more than one state.
(p) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides coverage for
hospital, surgical or medical care shall provide the following coverage
for mammography screening for occult breast cancer:
(A) upon the recommendation of a physician, a mammogram at any age for
covered persons having a prior history of breast cancer or who have a
first degree relative with a prior history of breast cancer;
(B) a single baseline mammogram for covered persons aged thirty-five
through thirty-nine, inclusive; and
(C) an annual mammogram for covered persons aged forty and older.
(D) The coverage required in this paragraph or paragraph two of this
subsection may be subject to annual deductibles and coinsurance as may
be deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given contract.
(2) For purposes of paragraph one of this subsection, mammography
screening means an X-ray examination of the breast using dedicated
equipment, including X-ray tube, filter, compression device, screens,
films and cassettes, with an average glandular radiation dose less than
0.5 rem per view per breast.
(3) In addition to paragraph one or two of this subsection, every
contract that provides coverage for hospital, surgical or medical care,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following mammography
screening services, and such coverage shall not be subject to annual
deductibles or coinsurance:
(A) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for mammography not described in subparagraph (A) of this
paragraph and as provided for in comprehensive guidelines supported by
the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(q) (1) Every policy issued by a medical expense indemnity
corporation, a hospital service corporation or a health service
corporation which provides coverage for prescribed drugs approved by the
food and drug administration of the United States government for the
treatment of certain types of cancer shall not exclude coverage of any
such drug on the basis that such drug has been prescribed for the
treatment of a type of cancer for which the drug has not been approved
by the food and drug administration. Provided, however, that such drug
must be recognized for treatment of the specific type of cancer for
which the drug has been prescribed in one of the following established
reference compendia:
(i) the American Hospital Formulary Service-Drug Information
(AHFS-DI);
(ii) National Comprehensive Cancer Networks Drugs and Biologics
Compendium;
(iii) Thomson Micromedex DrugDex;
(iv) Elsevier Gold Standard's Clinical Pharmacology; or other
authoritative compendia as identified by the Federal Secretary of Health
and Human Services or the Centers for Medicare & Medicaid Services
(CMS); or recommended by review article or editorial comment in a major
peer reviewed professional journal.
(2) Notwithstanding the provisions of this subsection, coverage shall
not be required for any experimental or investigational drugs or any
drug which the food and drug administration has determined to be
contraindicated for treatment of the specific type of cancer for which
the drug has been prescribed. The provisions of this subsection shall
apply to cancer drugs only and nothing herein shall be construed to
create, impair, alter, limit, modify, enlarge, abrogate or prohibit
reimbursement for drugs used in the treatment of any other disease or
condition.
(q-1) (1) Every contract issued by a medical expense indemnity
corporation, a hospital service corporation or a health service
corporation for delivery in this state that provides medical, major
medical or similar comprehensive-type coverage and provides coverage for
prescription drugs and for cancer chemotherapy treatment shall provide
coverage for prescribed, orally administered anticancer medications used
to kill or slow the growth of cancerous cells. Such coverage may be
subject to co-pays, coinsurance or deductibles, provided that the
co-pays, coinsurance or deductibles are at least as favorable to an
insured as the co-pays, coinsurance or deductibles that apply to
coverage for intravenous or injected anticancer medications.
(2) An insurer providing coverage under this paragraph and any
participating entity through which the insurer offers health services
shall not:
(A) vary the terms of the contract for the purpose or with the effect
of avoiding compliance with this paragraph;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
paragraph;
(C) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this paragraph;
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
paragraph intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this paragraph; or
(E) achieve compliance with this paragraph by imposing an increase in
cost sharing for an intravenous or injected anticancer medication.
(r) Consistent with federal law, a hospital service corporation or a
health service corporation which provides coverage supplementing part A
and part B of subchapter XVIII of the federal Social Security Act, 42
USC §§ 1395 et seq., shall make available and, if requested by a person
holding a direct payment individual contract or by all persons holding
individual contracts in a group whose premiums are paid by a remitting
agent or by a contract holder in the case of a group contract issued
pursuant to section four thousand three hundred five of this article,
provide coverage for at least ninety days of care in a nursing home as
defined in section twenty-eight hundred one of the public health law,
except when such coverage would duplicate coverage that is available
under the aforementioned subchapter XVIII. Such coverage shall be made
available at the inception of all new contracts and, with respect to all
other contracts at each anniversary date of the contract.
(1) Coverage shall be subject to a copayment of twenty-five dollars
per day.
(2) Brochures describing such coverage must be provided at the time of
application for all new contracts and thereafter on each anniversary
date of the contract, and with respect to all other contracts annually
at each anniversary date of the contract. Such brochures must be
approved by the superintendent in consultation with the commissioner of
health.
Such insurers shall report to the superintendent each year the number
of contract holders to whom such insurers have issued such policies for
nursing home coverage and the approximate number of persons covered by
such policies.
(3) The commensurate rate for the coverage must be approved by the
superintendent.
* (s) (1) A hospital service corporation or health service corporation
which provides coverage for hospital care shall not exclude coverage for
hospital care for diagnosis and treatment of correctable medical
conditions otherwise covered by the policy solely because the medical
condition results in infertility; provided, however that:
(A) subject to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical or medical procedures
provided as part of such hospital care which would correct malformation,
disease or dysfunction resulting in infertility; and
(B) provided, further however, that subject to the provisions of
paragraph three of this subsection, in no case shall such coverage
exclude diagnostic tests and procedures provided as part of such
hospital care that are necessary to determine infertility or that are
necessary in connection with any surgical or medical treatments or
prescription drug coverage provided pursuant to this subsection,
including such diagnostic tests and procedures as hysterosalpingogram,
hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post
coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
and
(C) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with paragraph three of this subsection.
(2) A medical expense indemnity or health service corporation which
provides coverage for surgical and medical care shall not exclude
coverage for surgical and medical care for diagnosis and treatment of
correctable medical conditions otherwise covered by the policy solely
because the medical condition results in infertility; provided, however
that:
(A) subject to the provisions of paragraph three of this subsection,
in no case shall such coverage exclude surgical or medical procedures
which would correct malformation, disease or dysfunction resulting in
infertility; and
(B) provided, further however, that subject to the provisions of
paragraph three of this subsection, in no case shall such coverage
exclude diagnostic tests and procedures that are necessary to determine
infertility or that are necessary in connection with any surgical or
medical treatments or prescription drug coverage provided pursuant to
this subsection, including such diagnostic tests and procedures as
hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,
sono-hysterogram, post coital tests, testis biopsy, semen analysis,
blood tests and ultrasound; and
(C) provided, further however, every such policy which provides
coverage for prescription drugs shall include, within such coverage,
coverage for prescription drugs approved by the federal Food and Drug
Administration for use in the diagnosis and treatment of infertility in
accordance with paragraph three of this subsection.
(3) Coverage of diagnostic and treatment procedures, including
prescription drugs used in the diagnosis and treatment of infertility as
required by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
(A) 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.
(B) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this paragraph.
(C) 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.
(D) 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 paragraph "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.
(E) Coverage shall not be required to include the diagnosis and
treatment of infertility in connection with: (i) in vitro fertilization,
gamete intrafallopian tube transfers or zygote intrafallopian tube
transfers; (ii) the reversal of elective sterilizations; (iii) sex
change procedures; (iv) cloning; or (v) medical or surgical services or
procedures that are deemed to be experimental in accordance with
clinical guidelines referenced in subparagraph (F) of this paragraph.
(F) The superintendent, in consultation with the commissioner of
health, shall promulgate regulations which shall stipulate the
guidelines and standards which shall be used in carrying out the
provisions of this paragraph, which shall include:
(i) The 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.
(4) Every contract issued by a medical expense indemnity corporation,
a hospital service corporation or a health services corporation that
provides coverage for prescription fertility drugs and requires or
permits prescription drugs to be purchased through a network
participating mail order or other non-retail pharmacy shall provide the
same coverage for prescription fertility drugs when such drugs are
purchased from a network participating non-mail order retail pharmacy
provided that the network participating non-mail order retail pharmacy
agrees in advance, through a contractual network agreement, to the same
reimbursement amount, as well as the same applicable terms and
conditions, that the corporation has established for the network
participating mail order or other non-retail pharmacy. In such case, the
contract shall not impose any fee, co-payment, co-insurance, deductible
or other condition on any covered person who does not elect to purchase
prescription fertility drugs through a network participating mail order
or other non-retail pharmacy; provided, however, that the provisions of
this section shall not supersede the terms of a collective bargaining
agreement or apply to a contract that is the result of a collective
bargaining agreement between an employer and a recognized or certified
employee organization.
* NB There are 2 sb (s)'s
* (s) Notwithstanding any provision of a contract issued by a medical
expense indemnity corporation, a dental expense indemnity corporation or
health service corporation, every contract which provides coverage for
care provided through licensed health professionals who can bill for
services shall provide the same coverage and reimbursement for such
service provided pursuant to a clinical practice plan established
pursuant to subdivision fourteen of section two hundred six of the
public health law.
* NB There are 2 sb (s)'s
(t) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation that provides coverage for
hospital, surgical, or medical care shall provide coverage for an annual
cervical cytology screening for cervical cancer and its precursor states
for women aged eighteen and older. Such coverage required by this
paragraph may be subject to annual deductibles and coinsurance as may be
deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given contract.
(2) For purposes of paragraph one of this subsection, cervical
cytology screening shall include an annual pelvic examination,
collection and preparation of a Pap smear, and laboratory and diagnostic
services provided in connection with examining and evaluating the Pap
smear.
(3) In addition to paragraph one or two of this subsection, every
contract that provides coverage for hospital, surgical or medical care,
except for a grandfathered health plan under paragraph four of this
subsection, shall provide coverage for the following cervical cytology
screening services, and such coverage shall not be subject to annual
deductibles or coinsurance:
(A) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for cervical cytology not described in subparagraph (A) of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(4) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(u) (1) A medical expense indemnity corporation or a health service
corporation which provides medical coverage that includes coverage for
physician services in a physician's office and every policy which
provides major medical or similar comprehensive-type coverage shall
include coverage for the following equipment and supplies for the
treatment of diabetes, if recommended or prescribed by a physician or
other licensed health care provider legally authorized to prescribe
under title eight of the education law: blood glucose monitors and blood
glucose monitors for the visually impaired, data management systems,
test strips for glucose monitors and visual reading and urine testing
strips, insulin, injection aids, cartridges for the visually impaired,
syringes, insulin pumps and appurtenances thereto, insulin infusion
devices, and oral agents for controlling blood sugar. In addition, the
commissioner of the department of health shall provide and periodically
update by rule or regulation a list of additional diabetes equipment and
related supplies such as are medically necessary for the treatment of
diabetes, for which there shall also be coverage. Such policies shall
also include coverage for diabetes self-management education to ensure
that persons with diabetes are educated as to the proper self-management
and treatment of their diabetic condition, including information on
proper diets. Such coverage for self-management education and education
relating to diet shall be limited to visits medically necessary upon the
diagnosis of diabetes, where a physician diagnoses a significant change
in the patient's symptoms or conditions which necessitate changes in a
patient's self-management, or where reeducation or refresher education
is necessary. Such education may be provided by the physician or other
licensed health care provider legally authorized to prescribe under
title eight of the education law, or their staff, as part of an office
visit for diabetes diagnosis or treatment, or by a certified diabetes
nurse educator, certified nutritionist, certified dietitian or
registered dietitian upon the referral of a physician or other licensed
health care provider legally authorized to prescribe under title eight
of the education law. Education provided by the certified diabetes nurse
educator, certified nutritionist, certified dietitian or registered
dietitian may be limited to group settings wherever practicable.
Coverage for self-management education and education relating to diet
shall also include home visits when medically necessary.
(2) Such coverage may be subject to annual deductibles and coinsurance
as may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy.
(3) This subsection shall not apply to a policy which covers persons
employed in more than one state or the benefit structure of which was
the subject of collective bargaining affecting persons employed in more
than one state unless such policy is issued under the New York state
health insurance plan established under article eleven of the civil
service law or issued to or through a local government.
(v) (1) Every contract issued by a medical expense indemnity
corporation, hospital service corporation or health service corporation
which provides coverage for inpatient hospital care shall provide such
coverage for such period as is determined by the attending physician in
consultation with the patient to be medically appropriate after such
covered person has undergone a lymph node dissection or a lumpectomy for
the treatment of breast cancer or a mastectomy covered by the contract.
Such coverage may be subject to annual deductibles and coinsurance as
may be deemed appropriate by the superintendent and as are consistent
with those established for other benefits within a given policy. Written
notice of the availability of such coverage shall be delivered to the
group remitting agent or group contract holder prior to the inception of
such contract and annually thereafter.
(2) A medical expense indemnity corporation, hospital service
corporation or health service corporation which provides coverage under
this subsection and any participating entity through which the insurer
offers health services shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the contract or vary the
terms of the contract for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this subsection;
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection; or
(E) restrict coverage for any portion of a period within a hospital
length of stay required under this subsection in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay.
(3) The prohibitions in paragraph two of this subsection shall be in
addition to the provisions of sections four thousand three hundred
seventeen and four thousand three hundred eighteen of this article and
nothing in this paragraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(w)(1) Every contract issued by a medical expense indemnity
corporation or health service corporation which provides medical, major
medical, or similar comprehensive-type coverage must provide coverage
for a second medical opinion by an appropriate specialist, including but
not limited to a specialist affiliated with a specialty care center for
the treatment of cancer, in the event of a positive or negative
diagnosis of cancer or a recurrence of cancer or a recommendation of a
course of treatment for cancer, subject to the following:
(i) In the case of a contract that requires, or provides financial
incentives for, the covered person to receive covered services from
health care providers participating in a provider network maintained by
or under contract with the corporation, the contract shall include
coverage for a second medical opinion from a non-participating
specialist, including but not limited to a specialist affiliated with a
specialty care center for the treatment of cancer, when the attending
physician provides a written referral to a non-participating specialist,
at no additional cost to the covered person beyond what such covered
person would have paid for services from a participating appropriate
specialist. Provided however that nothing herein shall impair the
covered person's rights (if any) under the contract to obtain the second
medical opinion from a non-participating specialist without a written
referral, subject to the payment of additional coinsurance (if any)
required by the contract for services provided by non-participating
providers. The corporation shall compensate the non-participating
specialist at the usual, customary and reasonable rate, or at a rate
listed on a fee schedule filed and approved by the superintendent which
provides a comparable level of reimbursement.
(ii) In the case of a contract that does not provide financial
incentives for, and does not require, the covered person to receive
covered services from health care providers participating in a provider
network maintained by or under contract with the corporation, the
contract shall include coverage for a second medical opinion from a
specialist at no additional cost to the covered person beyond what the
covered person would have paid for comparable services covered under the
contract.
(iii) Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other benefits within a given
contract and, where applicable, consistent with the provisions of
subparagraphs (i) and (ii) of this paragraph.
Nothing in this subsection shall eliminate or diminish the
corporation's obligation to comply with the provisions of section four
thousand eight hundred four of this chapter and section forty-four
hundred three of the public health law where applicable. Written notice
of the availability of such coverage shall be delivered to the group
remitting agent or group contract holder prior to the inception of such
contract and annually thereafter.
(2) A medical expense indemnity corporation or health service
corporation which provides coverage under this subsection and any
participating entity through which the insurer offers health services
shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the contract or vary the
terms of the contract for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this subsection; or
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the effect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection.
(3) The prohibitions in paragraph two of this subsection shall be in
addition to the provisions of sections four thousand three hundred
seventeen and four thousand three hundred eighteen of this article and
nothing in this paragraph shall be construed to suspend, supersede,
amend or otherwise modify such sections.
(x)(1) Every contract issued by a medical expense indemnity
corporation, hospital service corporation or health service corporation
which provides coverage for surgical or medical care shall provide the
following coverage for breast reconstruction surgery after a mastectomy
or partial mastectomy:
(A) all stages of reconstruction of the breast on which the mastectomy
or partial mastectomy has been performed; and
(B) 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 or
coinsurance provisions as may be deemed appropriate by the
superintendent and as are consistent with those established for other
benefits within a given policy. Written notice of the availability of
such coverage shall be delivered to the group remitting agent or group
contract holder prior to the inception of such contract and annually
thereafter.
(2) A medical expense indemnity corporation, hospital service
corporation or health service corporation which provides coverage under
this subsection and any participating entity through which the insurer
offers health services shall not:
(A) deny to a covered person eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the policy or vary the
terms of the policy for the purpose or with the effect of avoiding
compliance with this subsection;
(B) provide incentives (monetary or otherwise) to encourage a covered
person to accept less than the minimum protections available under this
subsection;
(C) penalize in any way or reduce or limit the compensation of a
health care practitioner for recommending or providing care to a covered
person in accordance with this subsection;
(D) provide incentives (monetary or otherwise) to a health care
practitioner relating to the services provided pursuant to this
subsection intended to induce or have the affect of inducing such
practitioner to provide care to a covered person in a manner
inconsistent with this subsection;
(E) restrict coverage for any portion of a period within a hospital
length of stay required under this subsection in a manner which is
inconsistent with the coverage provided for any preceding portion of
such stay; or
(F) the prohibitions in this paragraph shall be in addition to the
provisions of sections four thousand three hundred seventeen and four
thousand three hundred eighteen of this article and nothing in this
paragraph shall be construed to suspend, supersede, amend or otherwise
modify such sections.
* (y) Every contract 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 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 sb (y)'s
* (y)(1) Every contract issued by a health service corporation or a
medical expense indemnity corporation which is a "managed care product"
as defined in paragraph four of this subsection that includes coverage
for physician services in a physician's office, and every "managed care
product" that provides major medical or similar comprehensive-type
coverage, shall include coverage for chiropractic care, as defined in
section six thousand five hundred fifty-one of the education law,
provided by a doctor of chiropractic licensed pursuant to article one
hundred thirty-two of the education law, in connection with the
detection or correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for the purpose
of removing nerve interference, and the effects thereof, where such
interference is the result of or related to distortion, misalignment or
subluxation of or in the vertebral column. However, chiropractic care
and services may be subject to reasonable deductible, co-payment and
co-insurance amounts, reasonable fee or benefit limits, and reasonable
utilization review, provided that any such amounts, limits and review:
(a) shall not function to direct treatment in a manner discriminative
against chiropractic care, and (b) individually and collectively shall
be no more restrictive than those applicable under the same policy to
care or services provided by other health professionals in the
diagnosis, treatment and management of the same or similar conditions,
injuries, complaints, disorders or ailments, even if differing
nomenclature is used to describe the condition, injury, complaint,
disorder or ailment. Nothing herein contained shall be construed as
impeding or preventing either the provision or coverage of chiropractic
care and services by duly licensed doctors of chiropractic, within the
lawful scope of chiropractic practice, in hospital facilities on a staff
or employee basis.
(3) Every contract issued by a health service corporation or a medical
expense indemnity corporation which includes coverage for physician
services in a physician's office, and every contract which provides
major medical or similar comprehensive-type coverage, other than a
"managed care product" as defined in paragraph four of this subsection,
shall provide coverage for chiropractic care, as defined in section six
thousand five hundred fifty-one of the education law, provided by a
doctor of chiropractic licensed pursuant to article one hundred
thirty-two of the education law, in connection with the detection or
correction by manual or mechanical means of structural imbalance,
distortion or subluxation in the human body for the purpose of removing
nerve interference, and the effects thereof, where such interference is
the result of or related to distortion, misalignment or subluxation of
or in the vertebral column. However, chiropractic care and services may
be subject to reasonable deductible, co-payment and co-insurance
amounts, reasonable fee or benefit limits, and reasonable utilization
review, provided that any such amounts, limits and review: (a) shall
not function to direct treatment in a manner discriminative against
chiropractic care, and (b) individually and collectively shall be no
more restrictive than those applicable under the same contract to care
or services provided by other health professionals in the diagnosis,
treatment and management of the same or similar conditions, injuries,
complaints, disorders or ailments even if differing nomenclature is used
to describe the condition, injury, complaint, disorder or ailment.
Nothing herein contained shall be construed as impeding or preventing
either the provision or coverage of chiropractic care and services by
duly licensed doctors of chiropractic, within the lawful scope of
chiropractic practice, in hospital facilities on a staff or employee
basis.
(4) For purposes of this subsection, a "managed care product" shall
mean a contract which requires that medical or other health care
services covered under the contract, other than emergency care services,
be provided by, or pursuant to a referral from, a primary care provider,
and that services provided pursuant to such a referral be rendered by a
health care provider participating in the corporation's managed care
provider network. In addition, a managed care product shall also mean
the in-network portion of a contract which requires that medical or
other health care services covered under the contract, other than
emergency care services, be provided by, or pursuant to a referral from,
a primary care provider, and that services provided pursuant to such a
referral be rendered by a health care provider participating in the
corporation's managed care provider network, in order for the insured to
be entitled to the maximum reimbursement under the contract.
(5) The coverage required by this subsection shall not be abridged by
any regulation promulgated by the superintendent.
* NB There are 2 sb (y)'s
(z) No contract issued by a medical expense indemnity corporation, a
hospital service corporation or a health service corporation shall
exclude coverage of a health care service, as defined in paragraph two
of subsection (e) of section four thousand nine hundred of this chapter,
rendered or proposed to be rendered to an insured on the basis that such
service is experimental or investigational, is rendered as part of a
clinical trial as defined in subsection (b-2) of section forty-nine
hundred of this chapter, or a prescribed pharmaceutical product
referenced in subparagraph (B) of paragraph two of subsection (e) of
section forty-nine hundred of this chapter provided that coverage of the
patient costs of such service has been recommended for the insured by an
external appeal agent upon an appeal conducted pursuant to subparagraph
(B) of paragraph four of subsection (b) of section four thousand nine
hundred fourteen of this chapter. The determination of the external
appeal agent shall be binding on the parties. For purposes of this
paragraph, patient costs shall have the same meaning as such term has
for purposes of subparagraph (B) of paragraph four of subsection (b) of
section four thousand nine hundred fourteen of this chapter; provided,
however, that coverage for the services required under this subsection
shall be provided subject to the terms and conditions generally
applicable to other benefits provided under the policy.
(z-1) (1) Every policy delivered or issued for delivery in this state
which provides medical coverage that includes coverage for physician
services in a physician's office and every policy which provides major
medical or similar comprehensive-type coverage shall provide, upon the
prescription of a health care provider legally authorized to prescribe
under title eight of the education law, the following coverage for
diagnostic screening for prostatic cancer:
(A) standard diagnostic testing including, but not limited to, a
digital rectal examination and a prostate-specific antigen test at any
age for men having a prior history of prostate cancer; and
(B) an annual standard diagnostic examination including, but not
limited to, a digital rectal examination and a prostate-specific antigen
test for men age fifty and over who are asymptomatic and for men age
forty and over with a family history of prostate cancer or other
prostate cancer risk factors.
(2) Such coverage 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.
(aa)(1) Every contract issued by a hospital service company or health
service corporation which provides major medical or similar
comprehensive-type coverage shall include coverage for prehospital
emergency medical services for the treatment of an emergency condition
when such services are provided by an ambulance service issued a
certificate to operate pursuant to section three thousand five of the
public health law.
(2) Payment by an insurer pursuant to this section shall be payment in
full for the services provided. An ambulance service reimbursed pursuant
to this section shall not charge or seek any reimbursement from, or have
any recourse against an insured for the services provided pursuant to
this subsection, except for the collection of copayments, coinsurance or
deductibles for which the insured is responsible for under the terms of
the policy.
(3) An insurer shall provide reimbursement for those services
prescribed by this section at rates negotiated between the insurer and
the provider of such services. In the absence of agreed upon rates, an
insurer shall pay for such services at the usual and customary charge,
which shall not be excessive or unreasonable.
(4) The provisions of this subsection shall have no application to
transfers of patients between hospitals or health care facilities by an
ambulance service as described in paragraph one of this subsection.
(5) As used in this subsection:
(A) "Prehospital emergency medical services" means the prompt
evaluation and treatment of an emergency medical condition, and/or
non-air-borne transportation of the patient to a hospital; provided
however, where the patient utilizes non-air-borne emergency
transportation pursuant to this subsection, reimbursement shall be based
on whether a prudent layperson, possessing an average knowledge of
medicine and health, could reasonably expect the absence of such
transportation to result in (i) placing the health of the person
afflicted with such condition in serious jeopardy, or in the case of a
behavioral condition placing the health of such person or others in
serious jeopardy; (ii) serious impairment to such person's bodily
functions; (iii) serious dysfunction of any bodily organ or part of such
person; (iv) serious disfigurement of such person; or (v) a condition
described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
Social Security Act.
(B) "Emergency condition" means a medical or behavioral condition that
manifests itself by acute symptoms of sufficient severity, including
severe pain, such that a prudent layperson, possessing an average
knowledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in (i) placing the health of the
person afflicted with such condition in serious jeopardy, or in the case
of a behavioral condition, placing the health of such person or others
in serious jeopardy; (ii) serious impairment to such person's bodily
functions; (iii) serious dysfunction of any bodily organ or part of such
person; (iv) serious disfigurement of such person; or (v) a condition
described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the
Social Security Act.
(bb) A health service corporation or a medical service expense
indemnity corporation that provides major medical or similar
comprehensive-type coverage shall provide such coverage for bone mineral
density measurements or tests, and if such contract otherwise includes
coverage for prescription drugs, drugs and devices approved by the
federal food and drug administration or generic equivalents as approved
substitutes. In determining appropriate coverage provided by paragraphs
one, two and three of this subsection, the insurer or health maintenance
organization shall adopt standards that include the criteria of the
federal Medicare program and the criteria of the national institutes of
health for the detection of osteoporosis, provided that such coverage
shall be further determined as follows:
(1) For purposes of paragraphs two and three of this subsection, bone
mineral density measurements or tests, drugs and devices shall include
those covered under the criteria of the federal Medicare program as well
as those in accordance with the criteria of the national institutes of
health, including, as consistent with such criteria, dual-energy x-ray
absorptiometry.
(2) For purposes of paragraphs one and three of this subsection, bone
mineral density measurements or tests, drugs and devices shall be
covered for individuals meeting the criteria for coverage, consistent
with the criteria under the federal Medicare program or the criteria of
the national institutes of health; provided that, to the extent
consistent with such criteria, individuals qualifying for coverage
shall, at a minimum, include individuals:
(i) previously diagnosed as having osteoporosis or having a family
history of osteoporosis; or
(ii) with symptoms or conditions indicative of the presence, or the
significant risk, of osteoporosis; or
(iii) on a prescribed drug regimen posing a significant risk of
osteoporosis; or
(iv) with lifestyle factors to such a degree as posing a significant
risk of osteoporosis; or
(v) with such age, gender and/or other physiological characteristics
which pose a significant risk for osteoporosis.
(3) Such coverage required pursuant to paragraph one or two of this
subsection may be subject to annual deductibles and coinsurance as may
be deemed appropriate by the superintendent and as are consistent with
those established for other benefits within a given policy.
(4) In addition to paragraph one, two or three of this subsection,
every contract that provides hospital, surgical or medical care
coverage, except for a grandfathered health plan under paragraph five of
this subsection, shall provide coverage for the following items or
services for bone mineral density, and such coverage shall not be
subject to annual deductibles or coinsurance:
(A) evidence-based items or services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations of
the United States preventive services task force; and
(B) with respect to women, such additional preventive care and
screenings for bone mineral density not described in subparagraph (A) of
this paragraph and as provided for in comprehensive guidelines supported
by the health resources and services administration.
(5) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
Affordable Care Act, 42 U.S.C. § 18011(e).
(cc) Every contract 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 contracts and certificates only
through the addition of a rider.
(1) Notwithstanding any other provision of this subsection, a
religious employer may request a contract without coverage for federal
food and drug administration approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so requested,
such contract shall be provided without coverage for contraceptive
methods. This paragraph shall not be construed to deny an enrollee
coverage of, and timely access to, contraceptive methods.
(A) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:
(i) The inculcation of religious values is the purpose of the entity.
(ii) The entity primarily employs persons who share the religious
tenets of the entity.
(iii) The entity serves primarily persons who share the religious
tenets of the entity.
(iv) The entity is a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(B) Every religious employer that invokes the exemption provided under
this paragraph shall provide written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
(2)(A) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
one of this subsection, each enrollee covered under the contract issued
to that group contractholder shall have the right to directly purchase
the rider required by this subsection from the insurer or health
maintenance organization which issued the group contract at the
prevailing small group community rate for such rider whether or not the
employee is part of a small group.
(B) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
one of this subsection, the insurer or health maintenance organization
that provides such coverage shall provide written notice to enrollees
upon enrollment with the insurer or health maintenance organization of
their right to directly purchase a rider for coverage for the cost of
contraceptive drugs or devices. The notice shall also advise the
enrollees of the additional premium for such coverage.
(3) Nothing in this subsection shall be construed as authorizing a
contract which provides coverage for prescription drugs to exclude
coverage for prescription drugs prescribed for reasons other than
contraceptive purposes.
(4) 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.
(dd) No health service corporation or medical service expense
indemnity corporation which provides medical, major medical or similar
comprehensive-type coverage shall exclude coverage for services covered
under such policy when provided by a comprehensive care center for
eating disorders pursuant to article twenty-seven-J of the public health
law; provided, however, that reimbursement by such corporation for
services provided through such comprehensive care centers shall, to the
extent possible and practicable, be structured in a manner to facilitate
the individualized, comprehensive and integrated plans of care which
such centers' network of practitioners and providers are required to
provide.
(ee) (1) A medical expense indemnity corporation, a hospital service
corporation or a health service corporation which provides coverage for
hospital or surgical care coverage shall not exclude coverage for
screening, diagnosis and treatment of medical conditions otherwise
covered by the contract solely because the treatment is provided to
diagnose or treat autism spectrum disorder.
(2) Every contract which provides physician services, medical, major
medical or similar comprehensive-type coverage shall provide coverage
for the screening, diagnosis and treatment of autism spectrum disorder
in accordance with this subsection and shall not exclude coverage for
the screening, diagnosis or treatment of medical conditions otherwise
covered by the contract because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the
superintendent and shall be consistent with those imposed on other
benefits under the contract. Coverage for applied behavior analysis
shall be subject to a maximum benefit of forty-five thousand dollars per
year per covered individual and such maximum annual benefit will
increase by the amount calculated from the average ten year rolling
average increase of the medical component of the consumer price index.
This paragraph shall not be construed as limiting the benefits that are
otherwise available to an individual under the contract, provided
however that such contract shall not contain any limitations on visits
that are solely applied to the treatment of autism spectrum disorder. No
insurer shall terminate coverage or refuse to deliver, execute, issue,
amend, adjust, or renew coverage to an individual solely because the
individual is diagnosed with autism spectrum disorder or has received
treatment for autism spectrum disorder. Coverage shall be subject to
utilization review and external appeals of health care services pursuant
to article forty-nine of this chapter as well as, case management, and
other managed care provisions.
(3) For purposes of this subsection:
(A) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS).
(B) "applied behavior analysis" means the design, implementation, and
evaluation of environmental modifications, using behavioral stimuli and
consequences, to produce socially significant improvement in human
behavior, including the use of direct observation, measurement, and
functional analysis of the relationship between environment and
behavior.
(C) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided or supervised by a behavior analyst certified
pursuant to the behavior analyst certification board, that are necessary
to develop, maintain, or restore, to the maximum extent practicable, the
functioning of an individual. Individuals that provide behavioral health
treatment under the supervision of a certified behavior analyst pursuant
to this subsection shall be subject to standards of professionalism,
supervision and relevant experience pursuant to regulations promulgated
by the superintendent in consultation with the commissioners of health
and education.
(D) "diagnosis of autism spectrum disorder" means assessments,
evaluations, or tests to diagnose whether an individual has autism
spectrum disorder.
(E) "pharmacy care" means medications prescribed by a licensed health
care provider legally authorized to prescribe under title eight of the
education law.
(F) "psychiatric care" means direct or consultative services provided
by a psychiatrist licensed in the state in which the psychiatrist
practices.
(G) "psychological care" means direct or consultative services
provided by a psychologist licensed in the state in which the
psychologist practices.
(H) "therapeutic care" means services provided by licensed or
certified speech therapists, occupational therapists, social workers, or
physical therapists.
(I) "treatment of autism spectrum disorder" shall include the
following care and assistive communication devices prescribed or ordered
for an individual diagnosed with autism spectrum disorder by a licensed
physician or a licensed psychologist:
(i) behavioral health treatment;
(ii) psychiatric care;
(iii) psychological care;
(iv) medical care provided by a licensed health care provider;
(v) therapeutic care, including therapeutic care which is deemed
habilitative or nonrestorative, in the event that the policy provides
coverage for therapeutic care; and
(vi) pharmacy care in the event that the contract provides coverage
for prescription drugs.
(4) Coverage may be denied on the basis that such treatment is being
provided to the covered person pursuant to an individualized education
plan under article eighty-nine of the education law. The provision of
services pursuant to an individualized family service plan under section
twenty-five hundred forty-five of the public health law, an
individualized education plan under article eighty-nine of the education
law, or an individualized service plan pursuant to regulations of the
office for persons with developmental disabilities shall not affect
coverage under the policy for services provided on a supplemental basis
outside of an educational setting if such services are prescribed by a
licensed physician or licensed psychologist.
(5) Nothing in this subsection shall be construed to affect any
obligation to provide services to an individual under an individualized
family service plan under section twenty-five hundred forty-five of the
public health law, an individualized education plan under article
eighty-nine of the education law, or an individualized service plan
pursuant to regulations of the office for persons with developmental
disabilities.
(6) Nothing in this subsection shall be construed to affect any
obligation to provide coverage for otherwise-covered services solely on
the basis that the services constitute early intervention program
services pursuant to section three thousand two hundred thirty-five-a of
this article or an individualized service plan pursuant to regulations
of the office for persons with developmental disabilities.
(7) Nothing in this subsection shall be construed to prevent a
contract from providing services through a network of participating
providers who shall meet certain requirements for participation,
including provider credentialing.
(ff) (1) No managed care contract issued by a health service
corporation, hospital service corporation or medical expense indemnity
corporation that provides coverage for hospital, medical or surgical
care shall provide that services of a participating hospital will be
covered as out-of-network services solely on the basis that the health
care provider admitting or rendering services to the insured is not a
participating provider.
(2) No managed care contract issued by a health service corporation,
hospital service corporation or medical expense indemnity corporation
that provides coverage for hospital, medical or surgical care shall
provide that services of a participating health care provider will be
covered as out-of-network services solely on the basis that the services
are rendered in a non-participating hospital.
(3) For purposes of this subsection, a "health care provider" is a
health care professional licensed, registered or certified pursuant to
title eight of the education law or a health care professional
comparably licensed, registered or certified by another state.
(4) For purposes of this subsection, a "managed care contract" is a
contract that requires that services be provided by a provider
participating in the corporation's network in order for the subscriber
to receive the maximum level of reimbursement under the contract.
* (gg) No medical expense indemnity corporation, a hospital service
corporation or a health service corporation which provides coverage for
prescription drugs and for which cost-sharing, deductibles or
co-insurance obligations are determined by category of prescription
drugs shall impose cost-sharing, deductibles or co-insurance obligations
for any prescription drug that exceeds the dollar amount of
cost-sharing, deductibles or co-insurance obligations for non-preferred
brand drugs or its equivalent (or brand drugs if there is no
non-preferred brand drug category).
* NB There are 2 sb§ (gg)'s
* (gg) (1) Every contract issued by a hospital service corporation,
health service corporation or medical expense indemnity corporation that
includes coverage for dialysis treatment that requires such services to
be provided by an in-network provider and that does not provide coverage
for out-of-network dialysis treatment shall not deny coverage of such
services because the services are provided by an out-of-network
provider, provided that each of the following conditions are met:
(A) The out-of-network provider is duly licensed to practice and
authorized to provide such treatment;
(B) The out-of-network provider is located outside the service area of
the insurer;
(C) The in-network healthcare provider treating the covered person for
the condition issues a written order for dialysis treatment stating that
in his or her opinion such treatment is necessary;
(D) The covered person has notified, in writing, the corporation at
least thirty days in advance of the proposed date or dates of such
out-of-network dialysis treatment. The notice shall include the
authorization required by subparagraph (C) of this paragraph. In the
event the covered person must travel on sudden notice due to family or
other emergency, shorter notice may be permitted, provided that the
corporation has reasonable opportunity to review the travel and
treatment plans of the covered person;
(E) The corporation shall have the right to pre-approve the dialysis
treatment and schedule; and
(F) Such coverage is limited to no greater than ten out-of-network
treatments in a calendar year.
(2) Where coverage for out-of-network dialysis treatment is provided
pursuant to paragraph one of this subsection, no corporation shall be
obligated to reimburse the out-of-network provider at an amount greater
than it would have paid for the same treatment within a network,
including all drugs and ancillary services tied to dialysis treatment,
and any amount charged by a provider in excess of the amount reimbursed
by the corporation shall be the responsibility of the covered person
receiving the out-of-network services.
(3) Such coverage of out-of-network dialysis services required by
paragraph one of this subsection shall otherwise be subject to the
limitations, exclusions and terms of the policy, including, but not
limited to, utilization review, annual deductibles, copayments, and
coinsurance, consistent with those required for other similar benefits
under the policy.
* NB There are 2 sb§ (gg)'s
* (hh) Notwithstanding title eleven of article five of the social
services law or any other law to the contrary, every policy which
provides coverage for prescription drugs shall, with regard to eye drop
medication requiring a prescription that has been approved by the
insurer for coverage, allow for the limited refilling of the
prescription prior to the last day of the approved dosage period without
regard to any coverage restrictions on early refill of renewals.
Provided, however, that any refill dispensed prior to the expiration of
the prescribed and approved coverage period pursuant to this subsection,
shall, to the extent practicable, be limited in quantity so as not to
exceed the remaining dosage initially approved for coverage. Provided,
further, that such limited refilling shall not limit or restrict
coverage with regard to any previously or subsequently approved
prescription for eye drop medication and shall be subject to the terms
and conditions of the policy otherwise applicable to this coverage.
Provided, further, that a pharmacist may contact the prescribing
physician or health care provider to verity the prescription.
* NB There are 2 sb§ (hh)'s
* (hh) Any contract issued by a medical expense indemnity corporation,
a hospital service corporation or a health services corporation that
provides coverage for prescription drugs shall permit each covered
person to fill any covered prescription that may be obtained at a
network participating mail order or other non-retail pharmacy, at the
covered person's option, at a network participating non-mail order
retail pharmacy provided that the network participating non-mail order
retail pharmacy agrees in advance, through a contractual network
agreement, to the same reimbursement amount, as well as the same
applicable terms and conditions, that the corporation has established
for the network participating mail order or other non-retail pharmacy.
In such a case, the contract shall not impose a copayment fee or other
condition on any covered person who elects to purchase drugs from a
network participating non-mail order retail pharmacy which is not also
imposed on covered persons electing to purchase drugs from a network
participating mail order or other non-retail pharmacy; provided,
however, that the provisions of this section shall not supersede the
terms of a collective bargaining agreement or apply to a contract that
is the result of a collective bargaining agreement between an employer
and a recognized or certified employee organization.
* NB There are 2 sb§ (hh)'s
(ii) Every contract issued by a corporation subject to the provisions
of this article which provides medical, major medical or similar
comprehensive-type coverage that includes coverage for a physical or
well care visit once in every three hundred sixty-five days shall be
interpreted to mean that such physical or well care visit can be had
once every calendar year, regardless of whether or not a period of three
hundred sixty-five days has passed since the previous physical or well
care visit.
Disclaimer: These codes may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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