Group or blanket accident and health insurance policies; standard provisions

§ 3221. Group or blanket accident and health insurance policies;\nstandard provisions. (a) No policy of group or blanket accident and\nhealth insurance shall, except as provided in subsection (d) hereof, be\ndelivered or issued for delivery in this state unless it contains in\nsubstance the following provisions or provisions which in the opinion of\nthe superintendent are more favorable to the holders of such\ncertificates or not less favorable to the holders of such certificates\nand more favorable to policyholders, provided however, that the\nprovisions set forth in paragraphs six and thirteen of this subsection\nshall not be applicable to any such policy which is issued to a\npolicyholder in accordance with subparagraph (E) of paragraph one of\nsubsection (c) of section four thousand two hundred thirty-five of this\nchapter:\n (1) (A) No statement made by the person insured shall avoid the\ninsurance or reduce benefits thereunder unless contained in a written\ninstrument signed by the person insured.\n (B) All statements contained in any such written instrument shall be\ndeemed representations and not warranties.\n (2) That no agent has authority to change the policy or waive any of\nits provisions and that no change in the policy shall be valid unless\napproved by an officer of the insurer and evidenced by endorsement on\nthe policy, or by amendment to the policy signed by the policyholder and\nthe insurer.\n (3) That all new employees or new members in the classes eligible for\ninsurance must be added to such class for which they are eligible.\n (4) That all premiums due under the policy shall be remitted by the\nemployer or employers of the persons insured or by some other designated\nperson acting on behalf of the association or group insured, to the\ninsurer on or before the due date thereof, with such period of grace as\nmay be specified therein.\n (5) The conditions under which the insurer may decline to renew the\npolicy.\n (6) That the insurer shall issue either to the employer or person in\nwhose name such policy is issued, for delivery to each member of the\ninsured group, a certificate setting forth in summary form a statement\nof the essential features of the insurance coverage and in substance the\nfollowing provisions of this subsection.\n (7) The ages, to which the insurance provided therein shall be\nlimited; and the ages, for which additional restrictions are placed on\nbenefits, and the additional restrictions placed on the benefits at such\nages.\n (8) That written notice of claim must be given to the insurer within\ntwenty days after the occurrence or commencement of any loss covered by\nthe policy. Failure to give notice within such time shall not invalidate\nor reduce any claim if it shall be shown not to have been reasonably\npossible to give such notice and that notice was given as soon as was\nreasonably possible.\n (9) That in the case of claim for loss of time for disability, written\nproof of such loss must be furnished to the insurer within thirty days\nafter the commencement of the period for which the insurer is liable,\nand that subsequent written proofs of the continuance of such disability\nmust be furnished to the insurer at such intervals as the insurer may\nreasonably require, and that in the case of claim for any other loss,\nwritten proof of such loss must be furnished to the insurer within one\nhundred twenty days after the date of such loss. Failure to furnish such\nproof within such time shall not invalidate or reduce any claim if it\nshall be shown not to have been reasonably possible to furnish such\nproof within such time, provided such proof was furnished as soon as\nreasonably possible.\n (10) That the insurer will furnish to the person making claim or to\nthe policyholder for delivery to such person such forms as are usually\nfurnished by it for filing proof of loss

ch time shall not invalidate or reduce any claim if it\nshall be shown not to have been reasonably possible to furnish such\nproof within such time, provided such proof was furnished as soon as\nreasonably possible.\n (10) That the insurer will furnish to the person making claim or to\nthe policyholder for delivery to such person such forms as are usually\nfurnished by it for filing proof of loss. If such forms are not\nfurnished before the expiration of fifteen days after the insurer\nreceives notice of any claim under the policy, the person making such\nclaim shall be deemed to have complied with the requirements of the\npolicy as to proof of loss upon submitting within the time fixed in the\npolicy for filing proof of loss, written proof covering the occurrence,\ncharacter and extent of the loss for which claim is made.\n (11) That the insurer shall have the right and opportunity to examine\nthe person of the individual for whom claim is made when and so often as\nit may reasonably require during the pendency of claim under the policy\nand also the right and opportunity to make an autopsy in case of death\nwhere it is not prohibited by law.\n (12) That benefits payable under the policy other than benefits for\nloss of time will be payable not more than sixty days after receipt of\nproof, and that, subject to due proof of loss all accrued benefits\npayable under the policy for loss of time will be paid not less\nfrequently than monthly during the continuance of the period for which\nthe insurer is liable, and that any balance remaining unpaid at the\ntermination of such period will be paid immediately upon receipt of such\nproof.\n (13) That indemnity for loss of life of the insured is payable in\naccordance with subsection (e) of section four thousand two hundred\nthirty-five of this chapter; and that all other indemnities of the\npolicy are payable to the insured, except as may be otherwise provided\nin accordance with such subsection; and that if a beneficiary is\ndesignated, the consent of the beneficiary shall not be requisite to\nchange of beneficiary, or to any other changes in the policy or\ncertificate, except as may be specifically provided by the policy.\n (14) That no action at law or in equity shall be brought to recover on\nthe policy prior to the expiration of sixty days after proof of loss has\nbeen filed in accordance with the requirements of the policy and that no\nsuch action shall be brought after the expiration of two years following\nthe time such proof of loss is required by the policy.\n (15) Any policy and certificate, other than one issued in fulfillment\nof the continuing care responsibilities of an operator of a continuing\ncare retirement community in accordance with article forty-six of the\npublic health law, made available because of residence in a particular\nfacility, housing development, or community shall contain the following\nnotice in twelve point type in bold face on the first page:\n "NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF\nA CONTINUING CARE RETIREMENT CONTRACT

continuing\ncare retirement community in accordance with article forty-six of the\npublic health law, made available because of residence in a particular\nfacility, housing development, or community shall contain the following\nnotice in twelve point type in bold face on the first page:\n "NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF\nA CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE\nWILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT\nCOMMUNITY."\n (16) No policy delivered or issued for delivery in this state which\nprovides coverage for prescription drugs and for which cost-sharing,\ndeductibles or co-insurance obligations are determined by category of\nprescription drugs shall impose cost-sharing, deductibles or\nco-insurance obligations for any prescription drug that exceeds the\ndollar amount of cost-sharing, deductibles or co-insurance obligations\nfor non-preferred brand drugs or its equivalent (or brand drugs if there\nis no non-preferred brand drug category).\n (17) Every policy delivered or issued for delivery in this state which\nprovides major medical or similar comprehensive-type coverage shall\nprovide space on any enrollment, renewal or initial online portal\nprocess setup forms required of an insured or applicant for insurance so\nthat the insured or applicant for insurance shall register or decline\nregistration in the donate life registry for organ, eye and tissue\ndonations under this section of the enrollment, renewal or initial\nonline portal process setup forms and that the following is stated on\nthe form in clear and conspicuous type:\n "You must fill out the following section: Would you like to be added\nto the Donate Life Registry? Check box for 'yes' or 'skip this\nquestion'."\n (b) No such policy shall be delivered or issued for delivery in this\nstate unless a schedule of the premium rates pertaining to such form\nshall have been filed with the superintendent.\n (c) Any portion of any such policy, which purports, by reason of the\ncircumstances under which a loss is incurred, to reduce any benefits\npromised thereunder to an amount less than that provided for the same\nloss occurring under ordinary circumstances, shall be printed, in such\npolicy and in each certificate issued thereunder, in bold face type and\nwith greater prominence than any other portion of the text of such\npolicy or certificate; and all other exceptions of the policy shall be\nprinted in the policy and in the certificate, with the same prominence\nas the benefits to which they apply. If any such policy contains any\nprovision which affects the liability of the insurer, on the grounds\nstated in subparagraph (J) or (K) of paragraph two of subsection (d) of\nsection three thousand two hundred sixteen of this article, then such\nprovision shall be contained in the policy and certificate in the form\nset forth in such section.\n (d) (1) The superintendent may approve any form of certificate to be\nissued under a blanket accident and health insurance policy as defined\nin section four thousand two hundred thirty-seven of this chapter, which\nomits or modifies any of the provisions hereinbefore required, if the\nsuperintendent deems such omission or modification suitable for the\ncharacter of such insurance and not unjust to the persons insured\nthereunder

prove any form of certificate to be\nissued under a blanket accident and health insurance policy as defined\nin section four thousand two hundred thirty-seven of this chapter, which\nomits or modifies any of the provisions hereinbefore required, if the\nsuperintendent deems such omission or modification suitable for the\ncharacter of such insurance and not unjust to the persons insured\nthereunder. Certificates issued under a policy or contract of student\naccident and health insurance as defined in section three thousand two\nhundred forty of this article shall comply with such section.\n (2) The superintendent may approve any form of group insurance policy\nproviding disability benefits to be issued pursuant to article nine of\nthe workers' compensation law which omits or modifies any of the\nprovisions hereinbefore required, if such omission or modification is\nnot inconsistent with the provisions of such article nine and he deems\nsuch omission or modification suitable for the character of such\ninsurance and not unjust to the persons insured thereunder.\n (3) The superintendent may also approve any form of group insurance\npolicy to be issued to a social services district pursuant to\nsubdivision two of section three hundred sixty-seven-a of the social\nservices law, which omits or modifies any of the provisions hereinbefore\nrequired, if he deems such omission or modification suitable for the\ncharacter of such insurance.\n (e) (1) A group policy providing hospital, medical or surgical expense\ninsurance for other than specific diseases or accident only, shall\nprovide that if the insurance on an employee or member insured under the\ngroup policy ceases because of termination of (A) employment or of\nmembership in the class or classes eligible for coverage under the\npolicy or (B) the policy, for any reason whatsoever, unless the\npolicyholder has replaced the group policy with similar and continuous\ncoverage for the same group whether insured or self-insured, such\nemployee or member who has been insured under the group policy shall be\nentitled to have issued to the insured by the insurer without evidence\nof insurability upon application made to the insurer within sixty days\nafter such termination, and payment of the quarterly, or, at the option\nof the employee or member, a less frequent premium applicable to the\nform and amount of insurance, an individual policy of insurance. The\ninsurer may, at its option elect to provide the insurance coverage under\na group insurance policy, delivered in this state, in lieu of the\nissuance of a converted individual policy of insurance. Such individual\npolicy, or group policy, as the case may be is hereafter referred to as\nthe converted policy. The benefits provided under the converted policy\nshall be those required by subsection (f) and (g) of this section, in\nthe event of termination of the converted group policy of insurance,\neach insured thereunder shall have a right of conversion to a converted\nindividual policy of insurance.\n (2) The insurer shall not be required to issue a converted policy\ncovering any person if such person is covered for similar benefits by\nanother hospital or surgical or medical expense insurance policy or\nhospital or medical service subscriber contract or medical practice or\nother prepayment plan or by any other plan or program or such person is\neligible for similar benefits, whether or not covered therefor, under\nany arrangement of coverage for individuals in a group, other than under\nthe converted policy, whether on an insured or uninsured basis or\nsimilar benefits are provided for or available to such person pursuant\nto any statute; and the benefits provided or available under any of such\nsources which together with the benefits provided under the converted\npolicy would result in overinsurance or duplication of benefits\naccording to standards on file with the superintendent.\n (3) The converted policy shall, at the option

ed basis or\nsimilar benefits are provided for or available to such person pursuant\nto any statute; and the benefits provided or available under any of such\nsources which together with the benefits provided under the converted\npolicy would result in overinsurance or duplication of benefits\naccording to standards on file with the superintendent.\n (3) The converted policy shall, at the option of the employee or\nmember, provide identical coverage for the dependents of such employee\nor member who were covered under the group policy. Provided, however,\nthat if the employee or member chooses the option of dependent coverage\nthen dependents acquired after the permitted time to convert stated in\nparagraph one of this subsection shall be added to the converted family\npolicy in accordance with the provisions of subsection (c) of section\nthirty-two hundred sixteen of this article and any regulations\npromulgated or guidelines issued by the superintendent. The effective\ndate of the individual's coverage under the converted policy shall be\nthe date of the termination of the individual's insurance under the\ngroup policy as to those persons covered under the group policy.\n (4) If delivery of an individual converted policy is to be made\noutside this state, it may be on such form as the insurer may then be\noffering for such conversion in the jurisdiction where such delivery is\nto be made.\n (5) The conversion provision shall also be available upon the death of\nthe employee or member, to the surviving spouse with respect to such of\nthe spouse and children as are then covered by the group policy, and\nshall be available to a child solely with respect to himself upon his\nattaining the limiting age of coverage under the group policy while\ncovered as a dependent thereunder. It shall also be available upon the\ndivorce or annulment of the marriage of the employee or member, to the\nformer spouse of such employee or member.\n (6) (A) Each certificate holder shall be given written notice of such\nconversion privilege and its duration within fifteen days before or\nafter the date of termination of group coverage, provided that if such\nnotice be given more than fifteen days but less than ninety days after\nthe date of termination of group coverage, the time allowed for the\nexercise of such privilege of conversion shall be extended for\nforty-five days after the giving of such notice. If such notice be not\ngiven within ninety days after the date of termination of group\ncoverage, the time allowed for the exercise of such conversion privilege\nshall expire at the end of such ninety days.\n (B) Written notice by the policyholder given to the certificate holder\nor mailed to the certificate holder's last known address, or written\nnotice by the insurer be sent by first class mail to the certificate\nholder at the last address furnished to the insurer by the policyholder,\nshall be deemed full compliance with the provisions of this subsection\nfor the giving of notice.\n (C) A group contract issued by an insurer may contain a provision to\nthe effect that notice of such conversion privilege and its duration\nshall be given by the policyholder to each certificate holder upon\ntermination of his group coverage.\n (7) In addition to the right of conversion herein, the employee or\nmember insured under the policy shall at his option, as an alternative\nto conversion, be entitled to have his coverage continued under the\ngroup policy in accordance with the conditions and limitations contained\nin subsection (m) of this section, and have issued at the end of the\nperiod of continuation an individual conversion policy subject to the\nterms of this subsection. The effective date for the conversion policy\nshall be the day following the termination of insurance under the group\npolicy, or if there is a continuation of coverage, on the day following\nthe end of the period of continuation

ed\nin subsection (m) of this section, and have issued at the end of the\nperiod of continuation an individual conversion policy subject to the\nterms of this subsection. The effective date for the conversion policy\nshall be the day following the termination of insurance under the group\npolicy, or if there is a continuation of coverage, on the day following\nthe end of the period of continuation. Notwithstanding the foregoing,\nthe superintendent may require conversion or continuation of insurance\nunder conditions as set forth in a regulation for insureds under a\npolicy issued in accordance with subparagraph (E) of paragraph one of\nsubsection (c) of section four thousand two hundred thirty-five of this\nchapter.\n (8) For purposes of this subsection, the term "dependent" shall\ninclude a child as described in subsection (f) of section four thousand\ntwo hundred thirty-five of this chapter.\n (f) If the group insurance policy insures the employee or member for\nhospital, medical or surgical expense insurance, or if the group\ninsurance policy insures the employee or member for major medical or\nsimilar comprehensive-type coverage, then the conversion privilege shall\nentitle the employee or member to obtain coverage under a converted\npolicy providing, at the insured's option, coverage under any one of the\nplans described in subsection (g) of this section on an expense incurred\nbasis.\n (g) For conversion purposes, an insurer shall offer to the employee or\nmember a policy at each level of coverage as defined in subsection (b)\nof section three thousand two hundred seventeen-i of this article that\ncontains the essential health benefits package described in paragraph\nthree of subsection (e) of section three thousand two hundred\nseventeen-i of this article. Provided, however, the superintendent may,\nafter giving due consideration to the public interest, approve a request\nmade by an insurer for the insurer to satisfy the requirements of this\nsubsection and subsections (e) and (f) of this section through the\noffering of policies that comply with this subsection by another\ninsurer, corporation or health maintenance organization within the\ninsurer's holding company system, as defined in article fifteen of this\nchapter.\n (h) Every small group policy or association group policy delivered or\nissued for delivery in this state that provides coverage for hospital,\nmedical or surgical expense insurance and is not a grandfathered health\nplan shall provide coverage for the essential health benefits package.\nFor purposes of this subsection:\n (1) "essential health benefits package" shall have the meaning set\nforth in paragraph three of subsection (e) of section three thousand two\nhundred seventeen-i of this article;\n (2) "grandfathered health plan" means coverage provided by an insurer\nin which an individual was enrolled on March twenty-third, two thousand\nten for as long as the coverage maintains grandfathered status in\naccordance with section 1251(e) of the affordable care act, 42 U.S.C. §\n18011(e);\n (3) "small group" means a group of one hundred or fewer employees or\nmembers exclusive of spouses and dependents; and\n (4) "association group" means a group defined in subparagraphs (B),\n(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section\nfour thousand two hundred thirty-five of this chapter, provided that:\n (A) the group includes one or more individual members; or\n (B) the group includes one or more member employers or other member\ngroups that are small groups.\n (i) An insurer shall not be required to offer the policyholder any\nbenefits that must be made available pursuant to this section if the\nbenefits must be covered pursuant to subsection (h) of this section

this chapter, provided that:\n (A) the group includes one or more individual members; or\n (B) the group includes one or more member employers or other member\ngroups that are small groups.\n (i) An insurer shall not be required to offer the policyholder any\nbenefits that must be made available pursuant to this section if the\nbenefits must be covered pursuant to subsection (h) of this section. For\nany policy issued within the health benefit exchange established by this\nstate, an insurer shall not be required to offer the policyholder any\nbenefits that must be made available pursuant to this section.\n (j) No policy of group or blanket accident and health insurance shall\nbe issued as excess coverage for volunteer firefighters over and above\nthe coverage provided for pursuant to the volunteer firefighters'\nbenefit law unless such excess policy provides for each of the types of\ncoverages set forth in subdivision one of section five of such law. Any\nexcess policy which does not contain such provisions shall be construed\nas if such coverages were embodied therein.\n (k) (1) (A) Every group policy delivered or issued for delivery in\nthis state which provides coverage for in-patient hospital care shall\nprovide coverage for home care to residents in this state, except that\nthis provision shall not apply to a policy which covers persons employed\nin more than one state or the benefit structure of which was the subject\nof collective bargaining affecting persons who are employed in more than\none state. Such home care coverage shall be included at the inception of\nall new policies and, with respect to all other policies, added at any\nanniversary date of the policy subject to evidence of insurability.\n (B) Such coverage may be subject to an annual deductible of not more\nthan fifty dollars for each person covered under the policy and may be\nsubject to a coinsurance provision which provides for coverage of not\nless than seventy-five percent of the reasonable charges for such\nservices.\n (C) Home care means the care and treatment of a covered person who is\nunder the care of a physician but only if hospitalization or confinement\nin a nursing facility as defined in subchapter XVIII of the federal\nSocial Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been\nrequired if home care was not provided, and the plan covering the home\nhealth service is established and approved in writing by such physician.\n (D) Home care shall be provided by an agency possessing a valid\ncertificate of approval or license issued pursuant to article thirty-six\nof the public health law and shall consist of one or more of the\nfollowing:\n (i) Part-time or intermittent home nursing care by or under the\nsupervision of a registered professional nurse (R.N.).\n (ii) Part-time or intermittent home health aide services which consist\nprimarily of caring for the patient.\n (iii) Physical, occupational or speech therapy if provided by the home\nhealth service or agency.\n (iv) Medical supplies, drugs and medications prescribed by a\nphysician, and laboratory services by or on behalf of a certified home\nhealth agency or licensed home care services agency to the extent such\nitems would have been covered under the contract if the covered person\nhad been hospitalized or confined in a skilled nursing facility as\ndefined in subchapter XVIII of the federal Social Security Act, 42\nU.S.C

es, drugs and medications prescribed by a\nphysician, and laboratory services by or on behalf of a certified home\nhealth agency or licensed home care services agency to the extent such\nitems would have been covered under the contract if the covered person\nhad been hospitalized or confined in a skilled nursing facility as\ndefined in subchapter XVIII of the federal Social Security Act, 42\nU.S.C. §§ 1395 et seq.\n (E) For the purpose of determining the benefits for home care\navailable to a covered person, each visit by a member of a home care\nteam shall be considered as one home care visit; the contract may\ncontain a limitation on the number of home care visits, but not less\nthan forty such visits in any calendar year or in any continuous period\nof twelve months, for each person covered under the contract; four hours\nof home health aide service shall be considered as one home care visit.\n (2) (A) Every insurer issuing a group policy delivered or issued for\ndelivery in this state which provides coverage for in-patient hospital\ncare shall include coverage for preadmission tests performed in hospital\nfacilities prior to scheduled surgery, except that this provision shall\nnot apply to a policy which covers persons employed in more than one\nstate or the benefit structure of which was the subject of collective\nbargaining affecting persons who are employed in more than one state.\n (B) Such policy shall provide benefits for tests ordered by a\nphysician which are performed in the out-patient facilities of a\nhospital as a planned preliminary to admission of the patient as an\nin-patient for surgery in the same hospital, provided that:\n (i) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed;\n (ii) reservations for a hospital bed and for an operating room were\nmade prior to the performance of the tests;\n (iii) the surgery actually takes place within seven days of such\npresurgical tests; and\n (iv) the patient is physically present at the hospital for the tests.\n (C) Coverage for abortion shall include coverage of any drug\nprescribed for the purpose of an abortion, including both generic and\nbrand name drugs, even if such drug has not been approved by the food\nand drug administration for abortion, provided, however, that such drug\nshall be a recognized medication for abortion in one of the following\nestablished reference compendia:\n (i) The WHO Model Lists of Essential Medicines;\n (ii) The WHO Abortion Care Guidance; or\n (iii) The National Academies of Science, Engineering, and Medicine\nConsensus Study Report.\n (3) Every group policy delivered or issued for delivery in this state\nwhich provides coverage for in-patient surgical care shall include\ncoverage for a second surgical opinion by a qualified physician on the\nneed for surgery, except that this provision shall not apply to a policy\nwhich covers persons employed in more than one state or the benefit\nstructure of which was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n (4) (A) Every group policy delivered or issued for delivery in this\nstate that provides coverage for inpatient hospital care shall include\ncoverage for services to treat an emergency condition provided in\nhospital facilities, except that this provision shall not apply to a\npolicy which covers persons employed in more than one state or the\nbenefit structure of which was the subject of collective bargaining\naffecting persons who are employed in more than one state unless the\npolicy otherwise provides coverage for services to treat an emergency\ncondition provided in hospital facilities:\n (i) without the need for any prior authorization determination;\n (ii) regardless of whether the health care provider furnishing such\nservices is a participating provider with respect to such services;\n (iii) if the emergency services are provided by

than one state unless the\npolicy otherwise provides coverage for services to treat an emergency\ncondition provided in hospital facilities:\n (i) without the need for any prior authorization determination;\n (ii) regardless of whether the health care provider furnishing such\nservices is a participating provider with respect to such services;\n (iii) if the emergency services are provided by a non-participating\nprovider, without imposing any administrative requirement or limitation\non coverage that is more restrictive than the requirements or\nlimitations that apply to emergency services received from participating\nproviders; and\n (iv) if the emergency services are provided by a non-participating\nprovider, the cost-sharing requirement (expressed as a copayment or\ncoinsurance) shall be the same requirement that would apply if such\nservices were provided by a participating provider.\n (B) Any requirements of section 2719A(b) of the Public Health Service\nAct, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the\nrequirements of this paragraph with respect to coverage of emergency\nservices shall be applicable to every policy subject to this paragraph.\n (C) In this paragraph, an "emergency condition" means a medical or\nbehavioral condition that manifests itself by acute symptoms of\nsufficient severity, including severe pain, such that a prudent\nlayperson, possessing an average knowledge of medicine and health, could\nreasonably expect the absence of immediate medical attention to result\nin (i) placing the health of the person afflicted with such condition in\nserious jeopardy, or in the case of a behavioral condition placing the\nhealth of such person or others in serious jeopardy; (ii) serious\nimpairment to such person's bodily functions; (iii) serious dysfunction\nof any bodily organ or part of such person; (iv) serious disfigurement\nof such person; or (v) a condition described in clause (i), (ii) or\n(iii) of section 1867(e)(1)(A) of the Social Security Act.\n (D) In this paragraph, "emergency services" means, with respect to an\nemergency condition: (i) a medical screening examination as required\nunder section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, which\nis within the capability of the emergency department of a hospital,\nincluding ancillary services routinely available to the emergency\ndepartment to evaluate such emergency medical condition: and (ii) within\nthe capabilities of the staff and facilities available at the hospital,\nsuch further medical examination and treatment as are required under\nsection 1867 of the Social Security Act, 42 U.S.C. § 1395dd, to\nstabilize the patient.\n (E) In this paragraph, "to stabilize" means, with respect to an\nemergency condition, to provide such medical treatment of the condition\nas may be necessary to assure, within reasonable medical probability,\nthat no material deterioration of the condition is likely to result from\nor occur during the transfer of the insured from a facility or to\ndeliver a newborn child (including the placenta).\n (5) (A) (i) Every group or blanket policy delivered or issued for\ndelivery in this state which provides hospital, surgical or medical\ncoverage shall include coverage for maternity care, including hospital,\nsurgical or medical care to the same extent that coverage is provided\nfor illness or disease under the policy. Such maternity care coverage,\nother than coverage for perinatal complications, shall include inpatient\nhospital coverage for mother and newborn for at least forty-eight hours\nafter childbirth for any delivery other than a caesarean section, and\nfor at least ninety-six hours after a caesarean section

cal care to the same extent that coverage is provided\nfor illness or disease under the policy. Such maternity care coverage,\nother than coverage for perinatal complications, shall include inpatient\nhospital coverage for mother and newborn for at least forty-eight hours\nafter childbirth for any delivery other than a caesarean section, and\nfor at least ninety-six hours after a caesarean section. Such coverage\nfor maternity care shall include the services of a midwife licensed\npursuant to article one hundred forty of the education law, practicing\nconsistent with section sixty-nine hundred fifty-one of the education\nlaw and affiliated or practicing in conjunction with a facility licensed\npursuant to article twenty-eight of the public health law, but no\ninsurer shall be required to pay for duplicative routine services\nactually provided by both a licensed midwife and a physician.\n (ii) Maternity care coverage shall also include, at minimum, parent\neducation, assistance and training in breast or bottle feeding, and the\nperformance of any necessary maternal and newborn clinical assessments.\n (iii) The mother shall have the option to be discharged earlier than\nthe time periods established in item (i) of this subparagraph. In such\ncase, the inpatient hospital coverage must include at least one home\ncare visit which shall be in addition to, rather than in lieu of, any\nhome health care coverage available under the policy. The policy must\ncover the home care visit, which may be requested at any time within\nforty-eight hours of the time of delivery (ninety-six hours in the case\nof caesarean section), and shall be delivered within twenty-four hours,\n(I) after discharge, or (II) of the time of the mother's request,\nwhichever is later. Such home care coverage shall be pursuant to the\npolicy and subject to the provisions of this subparagraph, and not\nsubject to deductibles, coinsurance or copayments.\n (B) Coverage provided under this paragraph for care and treatment\nduring pregnancy shall include provision for not less than two payments,\nat reasonable intervals and for services rendered, for prenatal care and\na separate payment for the delivery and postnatal care provided.\n * (D) Coverage provided under this paragraph for care and treatment\nduring pregnancy shall include medically necessary transvaginal\nultrasounds when recommended by nationally recognized clinical practice\nguidelines. For the purposes of this subparagraph, "nationally\nrecognized clinical practice guidelines" means evidence-based clinical\npractice guidelines informed by a systematic review of evidence and an\nassessment of the benefits, and risks of alternative care options\nintended to optimize patient care developed by independent organizations\nor medical professional societies utilizing a transparent methodology\nand reporting structure and with a conflict of interest policy.\n * NB Effective January 1, 2027\n (5-a) Every policy that provides medical, major medical, or similar\ncomprehensive-type coverage shall provide coverage for prenatal vitamins\nwhen prescribed by a health care practitioner licensed, certified, or\nauthorized under title eight of the education law, and acting within\ntheir lawful scope of practice.\n (6) (A) Every group policy issued or delivered in this state which\nprovides coverage for hospital care shall not exclude coverage for\nhospital care for diagnosis and treatment of correctable medical\nconditions otherwise covered by the policy solely because the medical\ncondition results in infertility; provided, however that:\n (i) subject to the provisions of subparagraph (C) of this paragraph,\nin no case shall such coverage exclude surgical or medical procedures\nprovided as part of such hospital care which would correct malformation,\ndisease or dysfunction resulting in infertility; and\n (ii) provided, further however, that subject to the provisions of\nsubparagraph (C) of this paragraph, in no case sha

er that:\n (i) subject to the provisions of subparagraph (C) of this paragraph,\nin no case shall such coverage exclude surgical or medical procedures\nprovided as part of such hospital care which would correct malformation,\ndisease or dysfunction resulting in infertility; and\n (ii) provided, further however, that subject to the provisions of\nsubparagraph (C) of this paragraph, in no case shall such coverage\nexclude diagnostic tests and procedures provided as part of such\nhospital care that are necessary to determine infertility or that are\nnecessary in connection with any surgical or medical treatments or\nprescription drug coverage provided pursuant to this paragraph,\nincluding such diagnostic tests and procedures as hysterosalpingogram,\nhysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post\ncoital tests, testis biopsy, semen analysis, blood tests and ultrasound;\nand\n (iii) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with subparagraph (C) of this paragraph.\n (B) Every group policy issued or delivered in this state which\nprovides coverage for surgical and medical care shall not exclude\ncoverage for surgical and medical care for diagnosis and treatment of\ncorrectable medical conditions otherwise covered by the policy solely\nbecause the medical condition results in infertility; provided, however\nthat:\n (i) subject to the provisions of subparagraph (C) of this paragraph,\nin no case shall such coverage exclude surgical or medical procedures\nwhich would correct malformation, disease or dysfunction resulting in\ninfertility; and\n (ii) provided, further however, that subject to the provisions of\nsubparagraph (C) of this paragraph, in no case shall such coverage\nexclude diagnostic tests and procedures that are necessary to determine\ninfertility or that are necessary in connection with any surgical or\nmedical treatments or prescription drug coverage provided pursuant to\nthis paragraph, including such diagnostic tests and procedures as\nhysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy,\nsono-hysterogram, post coital tests, testis biopsy, semen analysis,\nblood tests and ultrasound; and\n (iii) provided, further however, every such policy which provides\ncoverage for prescription drugs shall include, within such coverage,\ncoverage for prescription drugs approved by the federal Food and Drug\nAdministration for use in the diagnosis and treatment of infertility in\naccordance with subparagraph (C) of this paragraph.\n (C) Coverage of diagnostic and treatment procedures, including\nprescription drugs, used in the diagnosis and treatment of infertility\nas required by subparagraphs (A) and (B) of this paragraph shall be\nprovided in accordance with the provisions of this subparagraph.\n (i) Diagnosis and treatment of infertility shall be prescribed as part\nof a physician's overall plan of care and consistent with the guidelines\nfor coverage as referenced in this subparagraph.\n (ii) Coverage may be subject to co-payments, coinsurance and\ndeductibles as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy.\n (iii) Except as provided in items (vi) and (vii) of this subparagraph,\ncoverage shall not be required to include the diagnosis and treatment of\ninfertility in connection with: (I) in vitro fertilization, gamete\nintrafallopian tube transfers or zygote intrafallopian tube transfers;\n(II) the reversal of elective sterilizations; (III) sex change\nprocedures; (IV) cloning; or (V) medical or surgical services or\nprocedures that are deemed to be experimental in accordance with\nclinical guidelines referenced in item (iv) of this subparagraph.\n (

ility in connection with: (I) in vitro fertilization, gamete\nintrafallopian tube transfers or zygote intrafallopian tube transfers;\n(II) the reversal of elective sterilizations; (III) sex change\nprocedures; (IV) cloning; or (V) medical or surgical services or\nprocedures that are deemed to be experimental in accordance with\nclinical guidelines referenced in item (iv) of this subparagraph.\n (iv) The superintendent, in consultation with the commissioner of\nhealth, shall promulgate regulations which shall stipulate the\nguidelines and standards which shall be used in carrying out the\nprovisions of this subparagraph, which shall include:\n (I) The identification of experimental procedures and treatments not\ncovered for the diagnosis and treatment of infertility determined in\naccordance with the standards and guidelines established and adopted by\nthe American College of Obstetricians and Gynecologists and the American\nSociety for Reproductive Medicine;\n (II) The identification of the required training, experience and other\nstandards for health care providers for the provision of procedures and\ntreatments for the diagnosis and treatment of infertility determined in\naccordance with the standards and guidelines established and adopted by\nthe American College of Obstetricians and Gynecologists and the American\nSociety for Reproductive Medicine; and\n (III) The determination of appropriate medical candidates by the\ntreating physician in accordance with the standards and guidelines\nestablished and adopted by the American College of Obstetricians and\nGynecologists and/or the American Society for Reproductive Medicine.\n (v)(I) For the purposes of this paragraph, "infertility" means a\ndisease or condition characterized by the incapacity to impregnate\nanother person or to conceive, defined by the failure to establish a\nclinical pregnancy after twelve months of regular, unprotected sexual\nintercourse or therapeutic donor insemination, or after six months of\nregular, unprotected sexual intercourse or therapeutic donor\ninsemination for a female thirty-five years of age or older. Earlier\nevaluation and treatment may be warranted based on an individual's\nmedical history or physical findings.\n (II) For purposes of this paragraph, "iatrogenic infertility" means an\nimpairment of fertility by surgery, radiation, chemotherapy or other\nmedical treatment affecting reproductive organs or processes.\n (vi) Coverage shall also include standard fertility preservation\nservices when a medical treatment may directly or indirectly cause\niatrogenic infertility to an insured. Coverage may be subject to annual\ndeductibles and coinsurance, including copayments, as may be deemed\nappropriate by the superintendent and as are consistent with those\nestablished for other benefits within a given policy.\n (vii) Every large group policy delivered or issued for delivery in\nthis state that provides medical, major medical or similar\ncomprehensive-type coverage shall provide coverage for three cycles of\nin-vitro fertilization used in the treatment of infertility. Coverage\nmay be subject to annual deductibles and coinsurance, including\ncopayments, as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy

ovides medical, major medical or similar\ncomprehensive-type coverage shall provide coverage for three cycles of\nin-vitro fertilization used in the treatment of infertility. Coverage\nmay be subject to annual deductibles and coinsurance, including\ncopayments, as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy. For purposes of this item, a "cycle" is defined as either all\ntreatment that starts when: preparatory medications are administered for\novarian stimulation for oocyte retrieval with the intent of undergoing\nin-vitro fertilization using a fresh embryo transfer; or medications are\nadministered for endometrial preparation with the intent of undergoing\nin-vitro fertilization using a frozen embryo transfer.\n (viii) No insurer providing coverage under this paragraph shall\ndiscriminate based on an insured's expected length of life, present of\npredicted disability, degree of medical dependency, perceived quality of\nlife, or other health conditions, nor based on personal characteristics,\nincluding age, sex, sexual orientation, marital status or gender\nidentity.\n (D) Every policy that provides coverage for prescription fertility\ndrugs and requires or permits prescription drugs to be purchased through\na network participating mail order or other non-retail pharmacy shall\nprovide the same coverage for prescription fertility drugs when such\ndrugs are purchased from a network participating non-mail order retail\npharmacy provided that the network participating non-mail order retail\npharmacy agrees in advance through a contractual network agreement, to\nthe same reimbursement amount, as well as the same applicable terms and\nconditions, that the insurer has established for a network participating\nmail order or other non-retail pharmacy. In such case, the policy shall\nnot impose any fee, co-payment, co-insurance, deductible or other\ncondition on any covered person who elects to purchase prescription\nfertility drugs through a network participating non-mail order retail\npharmacy that it does not impose on any covered person who purchases\nprescription fertility drugs through a network participating mail order\nor other non-retail pharmacy; provided, however, that the provisions of\nthis section shall not supersede the terms of a collective bargaining\nagreement or apply to a policy that is the result of a collective\nbargaining agreement between an employer and a recognized or certified\nemployee organization.\n (7)(A) Every group or blanket accident and health insurance policy\nissued or issued for delivery in this state which provides medical\ncoverage that includes coverage for physician services in a physician's\noffice and every policy which provides major medical or similar\ncomprehensive-type coverage shall include coverage for the following\nequipment and supplies for the treatment of diabetes, if recommended or\nprescribed by a physician or other licensed health care provider legally\nauthorized to prescribe under title eight of the education law: blood\nglucose monitors and blood glucose monitors for the visually impaired,\ndata management systems, test strips for glucose monitors and visual\nreading and urine testing strips, insulin, injection aids, cartridges\nfor the visually impaired, syringes, insulin pumps and appurtenances\nthereto, insulin infusion devices, and oral agents for controlling blood\nsugar. In addition, the commissioner of the department of health shall\nprovide and periodically update by rule or regulation a list of\nadditional diabetes equipment and related supplies such as are medically\nnecessary for the treatment of diabetes, for which there shall also be\ncoverage

, insulin pumps and appurtenances\nthereto, insulin infusion devices, and oral agents for controlling blood\nsugar. In addition, the commissioner of the department of health shall\nprovide and periodically update by rule or regulation a list of\nadditional diabetes equipment and related supplies such as are medically\nnecessary for the treatment of diabetes, for which there shall also be\ncoverage. Such policies shall also include coverage for diabetes\nself-management education to ensure that persons with diabetes are\neducated as to the proper self-management and treatment of their\ndiabetic condition, including information on proper diets. Such coverage\nfor self-management education and education relating to diet shall be\nlimited to visits medically necessary upon the diagnosis of diabetes,\nwhere a physician diagnoses a significant change in the patient's\nsymptoms or conditions which necessitate changes in a patient's\nself-management, or where reeducation or refresher education is\nnecessary. Such education may be provided by the physician or other\nlicensed health care provider legally authorized to prescribe under\ntitle eight of the education law, or their staff, as part of an office\nvisit for diabetes diagnosis or treatment, or by a certified diabetes\nnurse educator, certified nutritionist, certified dietitian or\nregistered dietitian upon the referral of a physician or other licensed\nhealth care provider legally authorized to prescribe under title eight\nof the education law. Education provided by the certified diabetes nurse\neducator, certified nutritionist, certified dietitian or registered\ndietitian may be limited to group settings wherever practicable.\nCoverage for self-management education and education relating to diet\nshall also include home visits when medically necessary.\n (B) Such coverage may be subject to annual deductibles and coinsurance\nas may be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy;\nprovided, however, that covered prescription insulin drugs shall not be\nsubject to a deductible, copayment, coinsurance or any other cost\nsharing requirement.\n (C) This paragraph shall not apply to a policy which covers persons\nemployed in more than one state or the benefit structure of which was\nthe subject of collective bargaining affecting persons employed in more\nthan one state unless such policy is issued under the New York state\nhealth insurance plan established under article eleven of the civil\nservice law or issued to or through a local government.\n (8) (A) Every group or blanket policy delivered or issued for delivery\nin this state which provides coverage for inpatient hospital care shall\nprovide such coverage for such period as is determined by the attending\nphysician in consultation with the patient to be medically appropriate\nfor such covered person undergoing a lymph node dissection or a\nlumpectomy for the treatment of breast cancer or a mastectomy covered by\nthe policy. Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy

h the patient to be medically appropriate\nfor such covered person undergoing a lymph node dissection or a\nlumpectomy for the treatment of breast cancer or a mastectomy covered by\nthe policy. Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy. Written notice of the availability of such coverage shall be\ndelivered to the policyholder prior to inception of such policy and\nannually thereafter.\n (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n (v) restrict coverage for any portion of a period within a hospital\nlength of stay required under this paragraph in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n (C) The prohibitions in subparagraph (B) of this paragraph shall be in\naddition to the provisions of sections three thousand two hundred\nthirty-one and three thousand two hundred thirty-two of this article and\nnothing in this subparagraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (9)(A) Every policy which provides medical, major medical, or similar\ncomprehensive-type coverage must provide coverage for a second medical\nopinion by an appropriate specialist, including but not limited to a\nspecialist affiliated with a specialty care center for the treatment of\ncancer, in the event of a positive or negative diagnosis of cancer or a\nrecurrence of cancer or a recommendation of a course of treatment for\ncancer, subject to the following:\n (i) In the case of a policy that requires, or provides financial\nincentives for, the insured to receive covered services from health care\nproviders participating in a provider network maintained by or under\ncontract with the insurer, the policy shall include coverage for a\nsecond medical opinion from a non-participating specialist, including\nbut not limited to a specialist affiliated with a specialty care center\nfor the treatment of cancer, when the attending physician provides a\nwritten referral to a non-participating specialist, at no additional\ncost to the insured beyond what such insured would have paid for\nservices from a participating appropriate specialist. Provided, however\nthat nothing herein shall impair an insured's rights (if any) under the\npolicy to obtain the second medical opinion from a non-participating\nspecialist without a written referral, subject to the payment of\nadditional coinsurance (if any) required by the policy for services\nprovided by non-participating providers

paid for\nservices from a participating appropriate specialist. Provided, however\nthat nothing herein shall impair an insured's rights (if any) under the\npolicy to obtain the second medical opinion from a non-participating\nspecialist without a written referral, subject to the payment of\nadditional coinsurance (if any) required by the policy for services\nprovided by non-participating providers. The insurer shall compensate\nthe non-participating specialist at the usual, customary and reasonable\nrate, or at a rate listed on a fee schedule filed and approved by the\nsuperintendent which provides a comparable level of reimbursement.\n (ii) In the case of a policy that does not provide financial\nincentives for, and does not require, the insured to receive covered\nservices from health care providers participating in a provider network\nmaintained by or under contract with the insurer, the policy shall\ninclude coverage for a second medical opinion from a specialist at no\nadditional cost to the insured beyond what the insured would have paid\nfor comparable services covered under the policy.\n (iii) Such coverage may be subject to annual deductibles and\ncoinsurance as may be deemed appropriate by the superintendent and as\nare consistent with those established for other benefits within a given\npolicy, and, where applicable, consistent with the provisions of clauses\n(i) and (ii) of this subparagraph.\n Nothing in this paragraph shall eliminate or diminish an insurer's\nobligation to comply with the provisions of section four thousand eight\nhundred four of this chapter where applicable. Written notice of the\navailability of such coverage shall be delivered to the policyholder\nprior to the inception of such policy and annually thereafter.\n (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which an insurer offers health services\nshall not:\n (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph; or\n (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the coverage provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph.\n (C) The prohibitions in subparagraph (B) of this paragraph shall be in\naddition to the provisions of sections three thousand two hundred\nthirty-one and three thousand two hundred thirty-two of this article and\nnothing in this subparagraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (10) (A) Every group or blanket policy delivered or issued for\ndelivery in this state which provides medical, major medical, or similar\ncomprehensive-type coverage shall provide the following coverage for\nbreast or chest wall reconstruction surgery after a mastectomy or\npartial mastectomy:\n (i) all stages of reconstruction of the breast or chest wall on which\nthe mastectomy or partial mastectomy has been performed; and\n (ii) surgery and reconstruction of the other breast or chest wall to\nproduce a symmetrical appearance;\nin the manner determined by the attending physician and the patient to\nbe appropriate. Chest wall reconstruction surgery shall include\naesthetic flat closure as such term is defined by the National Cancer\nInstitute

all on which\nthe mastectomy or partial mastectomy has been performed; and\n (ii) surgery and reconstruction of the other breast or chest wall to\nproduce a symmetrical appearance;\nin the manner determined by the attending physician and the patient to\nbe appropriate. Chest wall reconstruction surgery shall include\naesthetic flat closure as such term is defined by the National Cancer\nInstitute. Such coverage may be subject to annual deductibles and\ncoinsurance provisions as may be deemed appropriate by the\nsuperintendent and as are consistent with those established for other\nbenefits within a given policy. Written notice of the availability of\nsuch coverage shall be delivered to the policyholder prior to inception\nof such policy and annually thereafter.\n (A-1) Every group or blanket policy providing coverage as required by\nsubparagraph (A) of this paragraph shall also provide coverage for the\ntattooing of the nipple-areolar complex pursuant to or as part of such\nreconstruction if such tattooing is performed by a licensed physician or\nother health care practitioner licensed, certified, or authorized\npursuant to title eight of the education law and acting within their\nscope of practice.\n (B) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n (i) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the policy or vary the\nterms of the policy for the purpose or with the effect of avoiding\ncompliance with this paragraph;\n (ii) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n (iii) penalize in any way or reduce or limit the compensation of a\nhealth care practitioner for recommending or providing care to a covered\nperson in accordance with this paragraph;\n (iv) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nparagraph intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this paragraph; or\n (v) restrict coverage for any portion of a period within a hospital\nlength of stay required under this paragraph in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n (C) The prohibitions in this paragraph shall be in addition to the\nprovisions of sections three thousand two hundred thirty-one and three\nthousand two hundred thirty-two of this article and nothing in this\nparagraph shall be construed to suspend, supersede, amend or otherwise\nmodify such sections.\n * (11) Every policy that provides coverage for prescription drugs\nshall include coverage for the cost of enteral formulas for home use,\nwhether administered orally or via tube feeding, for which a physician\nor other licensed health care provider legally authorized to prescribe\nunder title eight of the education law has issued a written order. Such\nwritten order shall state that the enteral formula is clearly medically\nnecessary and has been proven effective as a disease-specific treatment\nregimen

teral formulas for home use,\nwhether administered orally or via tube feeding, for which a physician\nor other licensed health care provider legally authorized to prescribe\nunder title eight of the education law has issued a written order. Such\nwritten order shall state that the enteral formula is clearly medically\nnecessary and has been proven effective as a disease-specific treatment\nregimen. Specific diseases and disorders for which enteral formulas have\nbeen proven effective shall include, but are not limited to, inherited\ndiseases of amino-acid or organic acid metabolism; Crohn's Disease;\ngastroesophageal reflux; disorders of gastrointestinal motility such as\nchronic intestinal pseudo-obstruction; and multiple, severe food\nallergies including, but not limited to immunoglobulin E and\nnonimmunoglobulin E-mediated allergies to multiple food proteins; severe\nfood protein induced enterocolitis syndrome; eosinophilic disorders and\nimpaired absorption of nutrients caused by disorders affecting the\nabsorptive surface, function, length, and motility of the\ngastrointestinal tract. Enteral formulas that are medically necessary\nand taken under written order from a physician for the treatment of\nspecific diseases shall be distinguished from nutritional supplements\ntaken electively. Coverage for certain inherited diseases of amino acid\nand organic acid metabolism as well as severe protein allergic\nconditions shall include modified solid food products that are low\nprotein, contain modified protein, or are amino acid based that are\nmedically necessary.\n * NB There are 2 par (11)'s\n * (11)(A) Every policy which is a "managed care product" as defined in\nsubparagraph (D) of this paragraph that includes coverage for physician\nservices in a physician's office, and every policy which is a "managed\ncare product" that provides major medical or similar comprehensive-type\ncoverage shall include coverage for chiropractic care, as defined in\nsection six thousand five hundred fifty-one of the education law,\nprovided by a doctor of chiropractic licensed pursuant to article one\nhundred thirty-two of the education law, in connection with the\ndetection or correction by manual or mechanical means of structural\nimbalance, distortion or subluxation in the human body for the purpose\nof removing nerve interference, and the effects thereof, where such\ninterference is the result of or related to distortion, misalignment or\nsubluxation of or in the vertebral column. However, chiropractic care\nand services may be subject to reasonable deductible, co-payment and\nco-insurance amounts, reasonable fee or benefit limits, and reasonable\nutilization review, provided that any such amounts, limits and review:\n(a) shall not function to direct treatment in a manner discriminative\nagainst chiropractic care, and (b) individually and collectively shall\nbe no more restrictive than those applicable under the same policy to\ncare or services provided by other health professionals in the\ndiagnosis, treatment and management of the same or similar conditions,\ninjuries, complaints, disorders or ailments, even if differing\nnomenclature is used to describe the condition, injury, complaint,\ndisorder or ailment

(b) individually and collectively shall\nbe no more restrictive than those applicable under the same policy to\ncare or services provided by other health professionals in the\ndiagnosis, treatment and management of the same or similar conditions,\ninjuries, complaints, disorders or ailments, even if differing\nnomenclature is used to describe the condition, injury, complaint,\ndisorder or ailment. Nothing herein contained shall be construed as\nimpeding or preventing either the provision or coverage of chiropractic\ncare and services by duly licensed doctors of chiropractic, within the\nlawful scope of chiropractic practice, in hospital facilities on a staff\nor employee basis.\n (C) Every policy which includes coverage for physician services in a\nphysician's office, and every policy which provides major medical or\nsimilar comprehensive-type coverage, other than a "managed care product"\nas defined in subparagraph (D) of this paragraph, shall provide coverage\nfor chiropractic care, as defined in section six thousand five hundred\nfifty-one of the education law, provided by a doctor of chiropractic\nlicensed pursuant to article one hundred thirty-two of the education\nlaw, in connection with the detection or correction by manual or\nmechanical means of structural imbalance, distortion or subluxation in\nthe human body for the purpose of removing nerve interference, and the\neffects thereof, where such interference is the result of or related to\ndistortion, misalignment or subluxation of or in the vertebral column.\nHowever, chiropractic care and services may be subject to reasonable\ndeductible, co-payment and co-insurance amounts, reasonable fee or\nbenefit limits, and reasonable utilization review, provided that any\nsuch amounts, limits and review: (a) shall not function to direct\ntreatment in a manner discriminative against chiropractic care, and (b)\nindividually and collectively shall be no more restrictive that those\napplicable under the same policy to care or services provided by other\nhealth professionals in the diagnosis, treatment and management of the\nsame or similar conditions, injuries, complaints, disorders or ailments,\neven if differing nomenclature is used to describe the condition,\ninjury, complaint, disorder or ailment. Nothing herein contained shall\nbe construed as impeding or preventing either the provision or coverage\nof chiropractic care and services by duly licensed doctors of\nchiropractic, within the lawful scope of chiropractic practice, in\nhospital facilities on a staff or employee basis.\n (D) For purposes of this paragraph, a "managed care product" shall\nmean a policy which requires that medical or other health care services\ncovered under the policy, other than emergency care services, be\nprovided by, or pursuant to a referral from, a primary care provider,\nand that services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the insurer's managed care\nprovider network

h, a "managed care product" shall\nmean a policy which requires that medical or other health care services\ncovered under the policy, other than emergency care services, be\nprovided by, or pursuant to a referral from, a primary care provider,\nand that services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the insurer's managed care\nprovider network. In addition, a managed care product shall also mean\nthe in-network portion of a contract which requires that medical or\nother health care services covered under the contract, other than\nemergency care services, be provided by, or pursuant to a referral from,\na primary care provider, and that services provided pursuant to such a\nreferral be rendered by a health care provider participating in the\ninsurer's managed care provider network, in order for the insured to be\nentitled to the maximum reimbursement under the contract.\n (E) The coverage required by this paragraph shall not be abridged by\nany regulation promulgated by the superintendent.\n * NB There are 2 par (11)'s\n (12) No policy of group or blanket accident and health insurance\ndelivered or issued for delivery in this state shall exclude coverage of\na health care service, as defined in paragraph two of such subdivision\n(e) of section four thousand nine hundred of this chapter, rendered or\nproposed to be rendered to an insured on the basis that such service is\nexperimental or investigational, is rendered as part of a clinical trial\nas defined in subsection (b-2) of section forty-nine hundred of this\nchapter, or a prescribed pharmaceutical product referenced in\nsubparagraph (B) of paragraph two of subsection (e) of section\nforty-nine hundred of this chapter provided that coverage of the patient\ncosts of such service has been recommended for the insured by an\nexternal appeal agent upon an appeal conducted pursuant to subparagraph\n(B) of paragraph four of subsection (b) of section four thousand nine\nhundred fourteen of this chapter. The determination of the external\nappeal agent shall be binding on the parties. For purposes of this\nparagraph, patient costs shall have the same meaning as such term has\nfor purposes of subparagraph (B) of paragraph four of subsection (b) of\nsection four thousand nine hundred fourteen of this chapter; provided,\nhowever, that coverage for the services required under this paragraph\nshall be provided subject to the terms and conditions generally\napplicable to other benefits provided under the policy.\n (13) Every group or blanket policy delivered or issued for delivery in\nthis state that provides major medical or similar comprehensive-type\ncoverage shall provide such coverage for bone mineral density\nmeasurements or tests, and if such contract otherwise includes coverage\nfor prescription drugs, drugs and devices approved by the federal food\nand drug administration or generic equivalents as approved substitutes.\nIn determining appropriate coverage provided by subparagraphs (A), (B)\nand (C) of this paragraph, the insurer or health maintenance\norganization shall adopt standards that include the criteria of the\nfederal Medicare program and the criteria of the national institutes of\nhealth for the detection of osteoporosis, provided that such coverage\nshall be further determined as follows:\n (A) for purposes of subparagraphs (B) and (C) of this paragraph, bone\nmineral density measurements or tests, drugs and devices shall include\nthose covered under the federal Medicare program as well as those in\naccordance with the criteria of the national institutes of health,\nincluding, as consistent with such criteria, dual-energy x-ray\nabsorptiometry.\n (B) for purposes of subparagraphs (A) and (C) of this paragraph, bone\nmineral density measurements or tests, drugs and devices shall be\ncovered for individuals meeting the criteria under the federal Medicare\nprogram or the criteria of the national institutes of heal

criteria of the national institutes of health,\nincluding, as consistent with such criteria, dual-energy x-ray\nabsorptiometry.\n (B) for purposes of subparagraphs (A) and (C) of this paragraph, bone\nmineral density measurements or tests, drugs and devices shall be\ncovered for individuals meeting the criteria under the federal Medicare\nprogram or the criteria of the national institutes of health; provided\nthat, to the extent consistent with such criteria, individuals\nqualifying for coverage shall at a minimum, include individuals:\n (i) previously diagnosed as having osteoporosis or having a family\nhistory of osteoporosis; or\n (ii) with symptoms or conditions indicative of the presence, or the\nsignificant risk, of osteoporosis; or\n (iii) on a prescribed drug regimen posing a significant risk of\nosteoporosis; or\n (iv) with lifestyle factors to such a degree as posing a significant\nrisk of osteoporosis; or\n (v) with such age, gender and/or other physiological characteristics\nwhich pose a significant risk for osteoporosis.\n (C) Such coverage required pursuant to subparagraph (A) or (B) of this\nparagraph may be subject to annual deductibles and coinsurance as may be\ndeemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy.\n (D) In addition to subparagraph (A), (B) or (C) of this paragraph,\nevery group or blanket policy that provides hospital, surgical or\nmedical care coverage, except for a grandfathered health plan under\nsubparagraph (E) of this paragraph, shall provide coverage for the\nfollowing items or services for bone mineral density and such coverage\nshall not be subject to annual deductibles or coinsurance:\n (i) evidence-based items or services for bone mineral density that\nhave in effect a rating of 'A' or 'B' in the current recommendations of\nthe United States preventive services task force; and\n (ii) with respect to women, such additional preventive care and\nscreenings for bone mineral density not described in item (i) of this\nsubparagraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n (E) For purposes of this paragraph, "grandfathered health plan" means\ncoverage provided by an insurer in which an individual was enrolled on\nMarch twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\nAffordable Care Act, 42 U.S.C. § 18011(e).\n (14) No group or blanket policy delivered or issued for delivery in\nthis state which provides medical, major medical or similar\ncomprehensive-type coverage shall exclude coverage for services covered\nunder such policy when provided by a comprehensive care center for\neating disorders pursuant to article thirty of the mental hygiene law;\nprovided, however, that reimbursement under such policy for services\nprovided through such comprehensive care centers shall, to the extent\npossible and practicable, be structured in a manner to facilitate the\nindividualized, comprehensive and integrated plans of care which such\ncenters' network of practitioners and providers are required to provide.\n (15)(A) No group or blanket managed care health insurance policy that\nprovides coverage for hospital, medical or surgical care shall provide\nthat services of a participating hospital will be covered as\nout-of-network services solely on the basis that the health care\nprovider admitting or rendering services to the insured is not a\nparticipating provider.\n (B) No group or blanket managed care health insurance policy that\nprovides coverage for hospital, medical or surgical care shall provide\nthat services of a participating health care provider will be covered as\nout-of-network services solely on the basis that the services are\nrendered in a non-participating hospital.\n (C) For purposes of this paragraph, a "health care provider" is a\nhealth c

(B) No group or blanket managed care health insurance policy that\nprovides coverage for hospital, medical or surgical care shall provide\nthat services of a participating health care provider will be covered as\nout-of-network services solely on the basis that the services are\nrendered in a non-participating hospital.\n (C) For purposes of this paragraph, a "health care provider" is a\nhealth care professional licensed, registered or certified pursuant to\ntitle eight of the education law or a health care professional\ncomparably licensed, registered or certified by another state.\n (D) For purposes of this paragraph, a "managed care health insurance\npolicy" is a policy that requires that services be provided by a\nprovider participating in the insurer's network in order for the insured\nto receive the maximum level of reimbursement under the policy.\n (16)(A) Every group or blanket policy that includes coverage for\ndialysis treatment that requires such services to be provided by an\nin-network provider and that does not provide coverage for\nout-of-network dialysis treatment shall not deny coverage of such\nservices because the services are provided by an out-of-network\nprovider, provided that each of the following conditions are met:\n (i) The out-of-network provider is duly licensed to practice and\nauthorized to provide such treatment;\n (ii) The out-of-network provider is located outside the service area\nof the insurer;\n (iii) The in-network healthcare provider treating the insured for the\ncondition issues a written order for dialysis treatment stating that in\nhis or her opinion such treatment is necessary;\n (iv) The insured has notified, in writing, the insurer at least thirty\ndays in advance of the proposed date or dates of such out-of-network\ndialysis treatment. The notice shall include the authorization required\nby clause (iii) of this subparagraph. In the event the insured must\ntravel on sudden notice due to family or other emergency, shorter notice\nmay be permitted, provided that the insurer has reasonable opportunity\nto review the travel and treatment plans of the insured;\n (v) The insurer shall have the right to pre-approve the dialysis\ntreatment and schedule; and\n (vi) Such coverage is limited to no greater than ten out-of-network\ntreatments in a calendar year.\n (B) Where coverage for out-of-network dialysis treatment is provided\npursuant to subparagraph (A) of this paragraph, no insurer shall be\nobligated to reimburse the out-of-network provider at an amount greater\nthan it would have paid for the same treatment within a network,\nincluding all drugs and ancillary services tied to dialysis treatment,\nand any amount charged by a provider in excess of the amount reimbursed\nby the insurer shall be the responsibility of the insured receiving the\nout-of-network services.\n (C) Such coverage of out-of-network dialysis services required by\nsubparagraph (A) of this paragraph shall otherwise be subject to the\nlimitations, exclusions and terms of the policy, including, but not\nlimited to, utilization review, annual deductibles, copayments, and\ncoinsurance, consistent with those required for other similar benefits\nunder the policy.\n (17) Notwithstanding title eleven of article five of the social\nservices law or any other law to the contrary, every policy which\nprovides coverage for prescription drugs shall, with regard to eye drop\nmedication requiring a prescription that has been approved by the\ninsurer for coverage, allow for the limited refilling of the\nprescription prior to the last day of the approved dosage period without\nregard to any coverage restrictions on early refill of renewals.\nProvided, however, that any refill dispensed prior to the expiration of\nthe prescribed and approved coverage period pursuant to this paragraph,\nshall, to the extent practicable, be limited in quantity so as not to\nexceed the remaining dosage initially approved for coverage

or to the last day of the approved dosage period without\nregard to any coverage restrictions on early refill of renewals.\nProvided, however, that any refill dispensed prior to the expiration of\nthe prescribed and approved coverage period pursuant to this paragraph,\nshall, to the extent practicable, be limited in quantity so as not to\nexceed the remaining dosage initially approved for coverage. Provided,\nfurther, that such limited refilling shall not limit or restrict\ncoverage with regard to any previously or subsequently approved\nprescription for eye drop medication and shall be subject to the terms\nand conditions of the policy otherwise applicable to this coverage.\nProvided, further, that a pharmacist may contact the prescribing\nphysician or health care provider to verity the prescription.\n (18) Every group or blanket policy which provides medical, major\nmedical or similar comprehensive-type coverage that includes coverage\nfor a physical or well care visit once in every three hundred sixty-five\ndays shall be interpreted to mean that such physical or well care visit\ncan be had once every calendar year, regardless of whether or not a\nperiod of three hundred sixty-five days has passed since the previous\nphysical or well care visit.\n (19) Every group or blanket accident and health insurance policy\ndelivered or issued for delivery in this state that provides medical\ncoverage that includes coverage for physician services in a physician's\noffice and every policy that provides major medical or similar\ncomprehensive-type coverage shall include coverage for equipment and\nsupplies used for the treatment of ostomies, if prescribed by a\nphysician or other licensed health care provider legally authorized to\nprescribe under title eight of the education law. Such coverage shall be\nsubject to annual deductibles and coinsurance as deemed appropriate by\nthe superintendent. The coverage required by this paragraph shall be\nidentical to, and shall not enhance or increase the coverage required as\npart of essential health benefits as defined in subsection (a) of\nsection three thousand two hundred seventeen-i of this article.\n (20) No group or blanket policy delivered or issued for delivery in\nthis state that provides reimbursement for non-physician surgical first\nassistant services when the services are provided by a non-physician\nsurgical first assistant shall exclude such coverage on the basis that\nthe non-physician surgical first assistant services were performed by a\nregistered nurse first assistant provided that: (A) the registered nurse\nfirst assistant is certified in operating room nursing; (B) the services\nare within the scope of practice of a non-physician surgical first\nassistant; and (C) the terms and conditions of the policy otherwise\nprovide for the coverage of the services

\nthe non-physician surgical first assistant services were performed by a\nregistered nurse first assistant provided that: (A) the registered nurse\nfirst assistant is certified in operating room nursing; (B) the services\nare within the scope of practice of a non-physician surgical first\nassistant; and (C) the terms and conditions of the policy otherwise\nprovide for the coverage of the services. Nothing in this paragraph\nshall be construed to prevent the medical management or utilization\nreview of the services or prevent a policy from requiring that services\nare to be provided through a network of participating providers who meet\ncertain requirements for participation, including provider\ncredentialing.\n (21) Every group or blanket policy delivered or issued for delivery in\nthis state that provides coverage for prescription drugs subject to a\ncopayment shall charge a copayment for a limited initial prescription of\nan opioid drug, which is prescribed in accordance with paragraph (b) of\nsubdivision five of section thirty-three hundred one of the public\nhealth law, that is either (i) proportional between the copayment for a\nthirty-day supply and the amount of drugs the patient was prescribed; or\n(ii) equivalent to the copayment for a full thirty-day supply of the\nopioid drug, provided that no additional copayments may be charged for\nany additional prescriptions for the remainder of the thirty-day supply.\n (22) (A) Every policy which provides hospital, surgical, or medical\ncoverage and which offers maternity care coverage pursuant to paragraph\nfive of this subsection shall also provide coverage for abortion\nservices for an enrollee.\n (B) Coverage for abortion shall not be subject to annual deductibles\nor coinsurance, including co-payments, unless the policy is a high\ndeductible health plan as defined in section 223(c)(2) of the internal\nrevenue code of 1986, in which case coverage for abortion may be subject\nto the plan's annual deductible.\n (C) Notwithstanding any other provision, a group policy that provides\nhospital, surgical, or medical expense coverage delivered or issued for\ndelivery in this state to a religious employer, as defined in item one\nof subparagraph (E) of paragraph sixteen of subsection (l) of this\nsection, may exclude coverage for abortion only if the insurer:\n (i) obtains an annual certification from the group policyholder that\nthe policyholder is a religious employer and that the religious employer\nrequests a policy without coverage for abortion;\n (ii) issues a rider to each certificate holder at no premium to be\ncharged to the certificate holder or religious employer for the rider,\nthat provides coverage for abortion subject to the same rules as would\nhave been applied to the same category of treatment in the policy issued\nto the religious employer. The rider shall clearly and conspicuously\nspecify that the religious employer does not administer abortion\nbenefits, but that the insurer is issuing a rider for coverage of\nabortion, and shall provide the insurer's contact information for\nquestions; and\n (iii) provides notice of the issuance of the policy and rider to the\nsuperintendent in a form and manner acceptable to the superintendent.\n (23) (A) Every group or blanket policy of accident and health\ninsurance delivered or issued for delivery in this state which provides\nmajor medical or similar comprehensive-type coverage and provides\ncoverage for prescription drugs shall provide coverage for medically\nnecessary epinephrine devices for the emergency treatment of\nlife-threatening allergic reactions

ble to the superintendent.\n (23) (A) Every group or blanket policy of accident and health\ninsurance delivered or issued for delivery in this state which provides\nmajor medical or similar comprehensive-type coverage and provides\ncoverage for prescription drugs shall provide coverage for medically\nnecessary epinephrine devices for the emergency treatment of\nlife-threatening allergic reactions. Such coverage may be subject to\nannual deductibles and coinsurance as may be deemed appropriate by the\nsuperintendent; provided however, the total amount that an insured is\nrequired to pay out-of-pocket for such devices shall be capped at an\namount not to exceed one hundred dollars annually regardless of the\ninsured's deductible, copayment, coinsurance or any other cost-sharing\nrequirement. If under federal law, application of the annual cap would\nresult in health savings account ineligibility under 26 USC 223, such\ncoverage may be subject to the plan's annual deductible, except for with\nrespect to items or services that are preventive care pursuant to 26 USC\n223(c)(2)(C), in which case the requirements of this paragraph shall\napply regardless of whether the minimum deductible under 26 USC 223 has\nbeen satisfied.\n (B) For the purposes of this paragraph, "epinephrine device" shall\nhave the same meaning as provided in paragraph (b) of subdivision one of\nsection three thousand-c of the public health law.\n (l) (1) Every insurer delivering a group policy or issuing a group\npolicy for delivery in this state which provides coverage supplementing\npart A and part B of subchapter XVIII of the federal Social Security\nAct, 42 U.S.C. §§ 1395 et seq, must make available and, if requested by\nthe policyholder, provide coverage of supplemental home care visits\nbeyond those provided by part A and part B, sufficient to produce an\naggregate coverage of three hundred sixty-five home care visits per\npolicy year. Such coverage shall be provided pursuant to regulations\nprescribed by the superintendent. Written notice of the availability of\nsuch coverage shall be delivered to the policyholder prior to inception\nof such group policy and annually thereafter, except that this notice\nshall not be required where a policy covers two hundred or more\nemployees or where the benefit structure was the subject of collective\nbargaining affecting persons who are employed in more than one state.\n (2) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, which provides coverage for\nin-patient hospital care must make available, and if requested by the\npolicyholder, provide coverage for care in a nursing home. Written\nnotice of the availability of such coverage shall be delivered to the\npolicyholder prior to inception of such group policy and annually\nthereafter, except that this notice shall not be required where a policy\ncovers two hundred or more employees or where the benefit structure was\nthe subject of collective bargaining affecting persons who are employed\nin more than one state.\n (B) Such coverage shall be made available at the inception of all new\npolicies and, with respect to all other policies at any anniversary date\nof the policy subject to evidence of insurability.\n (C) In this paragraph, care in a nursing home means the continued care\nand treatment of a covered person who is under the care of a physician\nbut only if:\n (i) the care is provided in a nursing home as defined in section\ntwenty-eight hundred one of the public health law or a skilled nursing\nfacility as defined in subchapter XVIII of the federal Social Security\nAct, 42 U.S.C

insurability.\n (C) In this paragraph, care in a nursing home means the continued care\nand treatment of a covered person who is under the care of a physician\nbut only if:\n (i) the care is provided in a nursing home as defined in section\ntwenty-eight hundred one of the public health law or a skilled nursing\nfacility as defined in subchapter XVIII of the federal Social Security\nAct, 42 U.S.C. §§ 1395 et seq;\n (ii) the covered person has been in a hospital for at least three days\nimmediately preceding admittance to the nursing home or the skilled\nnursing facility; and\n (iii) further hospitalization would otherwise be necessary.\n (D) In determining the total days of coverage for nursing home care\nthe aggregate of the number of covered days of care in a hospital and\nthe number of covered days of care in a nursing home, with two days of\ncare in a nursing home equivalent to one day of care in a hospital, need\nnot exceed the number of covered days of hospital care provided under\nthe contract in a benefit period.\n (E) The level of benefits to be provided for nursing home care must be\nreasonably related to the benefits provided for hospital care.\n (3) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, which provides coverage for\nin-patient hospital care must make available and if requested by the\npolicyholder provide coverage to residents in this state for ambulatory\ncare in hospital out-patient facilities, as a hospital is defined in\nsection twenty-eight hundred one of the public health law, or subchapter\nXVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq, and\nphysicians' offices. Written notice of the availability of such coverage\nshall be delivered to the policyholder prior to inception of such group\npolicy and annually thereafter, except that this notice shall not be\nrequired where a policy covers two hundred or more employees or where\nthe benefit structure was the subject of collective bargaining affecting\npersons who are employed in more than one state.\n (B) In this paragraph:\n (i) "Ambulatory care in hospital out-patient facilities" means\nservices for diagnostic X-rays, laboratory and pathological\nexaminations, physical and occupational therapy and radiation therapy,\nand services and medications used for nonexperimental cancer\nchemotherapy and cancer hormone therapy, provided that such services and\nmedications are related to and necessary for the treatment or diagnosis\nof the patient's illness or injury, are ordered by a physician and, in\nthe case of physical therapy services, are to be furnished in connection\nwith the same illness for which the patient had been hospitalized or in\nconnection with surgical care, but in no event need benefits for\nphysical therapy be provided which commences more than six months after\ndischarge from a hospital or the date surgical care was rendered, and in\nno event need benefits for physical therapy be provided after three\nhundred sixty-five days from the date of discharge from a hospital or\nthe date surgical care was rendered.\n (ii) "Ambulatory care in physicians' offices" means services for\ndiagnostic X-rays, radiation therapy, laboratory and pathological\nexaminations, and services and medications used for nonexperimental\ncancer chemotherapy and cancer hormone therapy, provided that such\nservices and medications are related to and necessary for the treatment\nor diagnosis of the patient's illness or injury, and ordered by a\nphysician.\n (C) Such coverage shall be made available at the inception of all new\npolicies and, with respect to policies issued before January first,\nnineteen hundred eighty-three, at the first annual anniversary date\nthereafter, without evidence of insurability and at any subsequent\nannual anniversary date subject to evidence of insurability.\n (4) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state

t the inception of all new\npolicies and, with respect to policies issued before January first,\nnineteen hundred eighty-three, at the first annual anniversary date\nthereafter, without evidence of insurability and at any subsequent\nannual anniversary date subject to evidence of insurability.\n (4) (A) Every insurer delivering a group policy or issuing a group\npolicy for delivery, in this state, that provides reimbursement for\npsychiatric or psychological services or for the diagnosis and treatment\nof mental health conditions, however defined in such policy, by\nphysicians, psychiatrists or psychologists, shall provide the same\ncoverage to insureds for such services when performed by a licensed\nclinical social worker, within the lawful scope of his or her practice,\nwho is licensed pursuant to article one hundred fifty-four of the\neducation law and mental health counselors, marriage and family\ntherapists, and psychoanalysts licensed pursuant to article one hundred\nsixty-three of the education law, within the lawful scope of his or her\npractice. Nothing herein shall be construed to modify or expand the\nscope of practice of a mental health counselor, marriage and family\ntherapist, or psychoanalyst licensed pursuant to article one hundred\nsixty-three of the education law. Further, nothing herein shall be\nconstrued to create a new mandated health benefit.\n (B) The state board for social work shall maintain a list of all\nlicensed clinical social workers qualified for reimbursement under this\nparagraph.\n (C) Such coverage shall be made available at the inception of all new\npolicies and, with respect to all other policies at any subsequent\nannual anniversary date of the policy subject to evidence of\ninsurability.\n (E) The state board for social work shall maintain a list of all\nlicensed clinical social workers qualified for reimbursement under\nsubparagraph (D) of this paragraph.\n (5) (A) Every insurer delivering a group or school blanket policy or\nissuing a group or school blanket policy for delivery, in this state,\nwhich provides coverage for inpatient hospital care or coverage for\nphysician services shall provide coverage for the diagnosis and\ntreatment of mental health conditions and:\n * (i) where the policy provides coverage for inpatient hospital care,\nbenefits for inpatient care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law and benefits for outpatient\ncare provided in a facility issued an operating certificate by the\ncommissioner of mental health pursuant to the provisions of article\nthirty-one of the mental hygiene law, or in a facility operated by the\noffice of mental health or in a crisis stabilization center licensed\npursuant to section 36.01 of the mental hygiene law or, for care\nprovided in other states, to similarly licensed or certified hospitals\nor facilities; and\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (i) where the policy provides coverage for inpatient hospital care,\nbenefits for: inpatient care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law; sub-acute care in a\nresidential facility licensed or operated by the office of mental\nhealth; outpatient care provided by a facility issued an operating\ncertificate by the commissioner of mental health pursuant to the\nprovisions of article thirty-one of the mental hygiene law, or by a\nfacility operated by the office of mental health; outpatient care\nprovided by a crisis stabilization center licensed pursuant to section\n36.01 of the mental hygiene law; outpatient care provided by a mobile\ncrisis intervention services provider licensed, certified, or designated\nby the office of mental health or the office of addiction services and\nsupports; outpatient and inpatient care for critical time intervention\nservices and outpatient care for assertive commun

y a crisis stabilization center licensed pursuant to section\n36.01 of the mental hygiene law; outpatient care provided by a mobile\ncrisis intervention services provider licensed, certified, or designated\nby the office of mental health or the office of addiction services and\nsupports; outpatient and inpatient care for critical time intervention\nservices and outpatient care for assertive community treatment services\nprovided by facilities issued an operating certificate by the\ncommissioner of mental health pursuant to the provisions of article\nthirty-one of the mental hygiene law, beginning no later than thirty\ndays following discharge from a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law or the emergency department of\na hospital licensed pursuant to article twenty-eight of the public\nhealth law; or, for care provided in other states, to similarly licensed\nor certified hospitals, facilities, or licensed, certified or designated\nproviders; and\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n (ii) where the policy provides coverage for physician services, it\nshall include benefits for outpatient care provided by a psychiatrist or\npsychologist licensed to practice in this state, or a mental health\ncounselor, marriage and family therapist, or psychoanalyst licensed\npursuant to article one hundred sixty-three of the education law, or a\nlicensed clinical social worker within the lawful scope of his or her\npractice, who is licensed pursuant to article one hundred fifty-four of\nthe education law, a nurse practitioner licensed to practice in this\nstate, or a professional corporation or university faculty practice\ncorporation thereof. Nothing herein shall be construed to modify or\nexpand the scope of practice of a mental health counselor, marriage and\nfamily therapist, or psychoanalyst licensed pursuant to article one\nhundred sixty-three of the education law. Further, nothing herein shall\nbe construed to create a new mandated health benefit.\n (B) Coverage required by this paragraph may be subject to annual\ndeductibles, co-pays and coinsurance as may be deemed appropriate by the\nsuperintendent and shall be consistent with those imposed on other\nbenefits under the policy. Provided that no copayment or coinsurance\nimposed for outpatient mental health services provided in a facility\nlicensed, certified or otherwise authorized by the office of mental\nhealth shall exceed the copayments or coinsurance imposed for a primary\ncare office visit under the policy.\n (C) Coverage under this paragraph shall not apply financial\nrequirements or treatment limitations to mental health benefits that are\nmore restrictive than the predominant financial requirements and\ntreatment limitations applied to substantially all medical and surgical\nbenefits covered by the policy.\n (D) The criteria for medical necessity determinations under the policy\nwith respect to mental health benefits shall be made available by the\ninsurer to any insured, prospective insured, or in-network provider upon\nrequest.\n (E) For purposes of this paragraph:\n (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n * (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including

its\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy;\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (iv) "mental health condition" means any mental health disorder as\ndefined in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (iv) "mental health condition" means any mental health disorder as\ndefined in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases;\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (v) "assertive community treatment services" means a comprehensive\nand integrated combination of treatment, rehabilitation, case\nmanagement, and support services primarily provided in an insured's\nresidence or other community locations by a mobile multidisciplinary\nmental health treatment team licensed pursuant to article thirty-one of\nthe mental hygiene law;\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (vi) "critical time intervention services" means services rendered\nby a provider licensed under article thirty-one of the mental hygiene\nlaw that provides evidence-based, therapeutic interventions that include\nintensive outreach, engagement, and care coordination services that are\nprovided to an insured before the insured is discharged from inpatient\ncare in a hospital as defined by subdivision ten of section 1.03 of the\nmental hygiene law or the emergency department of a hospital licensed\npursuant to article twenty-eight of the public health law and continue\nafter discharge until the insured is sta

ntensive outreach, engagement, and care coordination services that are\nprovided to an insured before the insured is discharged from inpatient\ncare in a hospital as defined by subdivision ten of section 1.03 of the\nmental hygiene law or the emergency department of a hospital licensed\npursuant to article twenty-eight of the public health law and continue\nafter discharge until the insured is stabilized; and\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (vii) "residential facility" means crisis residence facilities and\ncommunity residences for eating disorder integrated treatment programs\nlicensed pursuant to article thirty-one of the mental hygiene law.\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n (F) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n (G) This subparagraph shall apply to hospitals and crisis residence\nfacilities in this state that are licensed or operated by the office of\nmental health that are participating in the insurer's provider network.\nWhere the policy provides coverage for inpatient hospital care, benefits\nfor inpatient hospital care in a hospital as defined by subdivision ten\nof section 1.03 of the mental hygiene law and benefits for sub-acute\ncare in a crisis residence facility licensed or operated by the office\nof mental health shall not be subject to preauthorization. Coverage\nprovided under this subparagraph shall also not be subject to concurrent\nutilization review for individuals who have not attained the age of\neighteen during the first fourteen days of the inpatient admission,\nprovided the facility notifies the insurer of both the admission and the\ninitial treatment plan within two business days of the admission,\nperforms daily clinical review of the insured, and participates in\nperiodic consultation with the insurer to ensure that the facility is\nusing the evidence-based and peer reviewed clinical review criteria\nutilized by the insurer which is approved by the office of mental health\nand appropriate to the age of the insured to ensure that the inpatient\ncare is medically necessary for the insured. For individuals who have\nattained age eighteen, coverage provided under this subparagraph shall\nalso not be subject to concurrent review during the first thirty days of\nthe inpatient or residential admission, provided the facility notifies\nthe insurer of both the admission and the initial treatment plan within\ntwo business days of the admission, performs daily clinical review of\nthe insured, and participates in periodic consultation with the insurer\nto ensure that the facility is using the evidence-based and peer\nreviewed clinical review criteria utilized by the insurer which is\napproved by the office of mental health and appropriate to the age of\nthe insured, to ensure that the inpatient or residential care is\nmedically necessary for the insured. However, concurrent review may be\nperformed during the first thirty days if an insured meets clinical\ncriteria designated by the office of mental health or where the insured\nis admitted to a hospital or facility which has been designated by the\noffice of mental health for concurrent review, in consultation with the\ncommissioner of health and the superintendent. All treatment provided\nunder this subparagraph may be reviewed retrospectively

ing the first thirty days if an insured meets clinical\ncriteria designated by the office of mental health or where the insured\nis admitted to a hospital or facility which has been designated by the\noffice of mental health for concurrent review, in consultation with the\ncommissioner of health and the superintendent. All treatment provided\nunder this subparagraph may be reviewed retrospectively. Where care is\ndenied retrospectively, an insured shall not have any financial\nobligation to the facility for any treatment under this subparagraph\nother than any copayment, coinsurance, or deductible otherwise required\nunder the policy.\n (H) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care by a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n * (I) This subparagraph shall apply to mobile crisis intervention\nservices providers licensed, certified, or designated by the office of\nmental health or the office of addiction services and supports. For\npurposes of this subparagraph, "mobile crisis intervention services"\nmeans mental health and substance use disorder services, consisting of:\n(1) telephonic crisis triage and response; (2) mobile crisis response to\nprovide intervention and facilitate access to other behavioral health\nservices; and (3) mobile and telephonic follow-up services after the\ninitial crisis response until the insured is stabilized provided to an\ninsured who is experiencing, or is at imminent risk of experiencing, a\nbehavioral health crisis, which includes instances in which an insured\ncannot manage their primarily psychiatric or substance use related\nsymptoms without de-escalation or intervention. Mobile crisis\nintervention services do not include services provided to an insured\nafter the insured has been stabilized.\n (i) Benefits for covered services provided by a mobile crisis\nintervention services provider shall not be subject to preauthorization.\nExcept where otherwise required by law, nothing in this subparagraph\nshall prevent services provided subsequent to the provision of mobile\ncrisis intervention services from being subject to preauthorization.\n (ii) Benefits for covered services provided by a mobile crisis\nintervention services provider shall be covered regardless of whether\nthe mobile crisis intervention services provider is a participating\nprovider.\n (iii) If the covered services are provided by a non-participating\nmobile crisis intervention services provider, an insurer shall not\nimpose any administrative requirement or limitation on coverage that is\nmore restrictive than the requirements or limitations that apply to\ncovered services received from a participating mobile crisis\nintervention services provider.\n (iv) If the covered services are provided by a non-participating\nmobile crisis intervention services provider, the insured's copayment,\ncoinsurance, and deductible shall be the same as would apply if such\ncovered services were provided by a participating mobile crisis\nintervention services provider.\n (v) A mobile crisis intervention services provider reimbursed pursuant\nto this section shall not charge or seek any reimbursement from, or have\nany recourse against, an insured for the services provided pursuant to\nthis subparagraph, except for the collection of in-network copayments,\ncoinsurance, or deductibles for which the insured is responsible for\nunder the terms of the policy.\n * NB Effective after the superintendent of financial services an

sed pursuant\nto this section shall not charge or seek any reimbursement from, or have\nany recourse against, an insured for the services provided pursuant to\nthis subparagraph, except for the collection of in-network copayments,\ncoinsurance, or deductibles for which the insured is responsible for\nunder the terms of the policy.\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n (J) This subparagraph shall apply to school-based mental health\nclinics that are licensed pursuant to article thirty-one of the mental\nhygiene law and provide outpatient care in pre-school, elementary, or\nsecondary schools. An insurer shall provide reimbursement for covered\noutpatient care when provided by such school-based mental health clinics\nat a pre-school, elementary, or secondary school, regardless of whether\nthe school-based mental health clinic furnishing such services is a\nparticipating provider with respect to such services. Reimbursement for\nsuch covered services shall be at the rate negotiated between the\ninsurer and school-based mental health clinic or, in the absence of a\nnegotiated rate, an amount no less than the rate that would be paid for\nsuch services pursuant to the medical assistance program under title\neleven of article five of the social services law. Payment by an insurer\npursuant to this section shall be payment in full for the services\nprovided. The school-based mental health clinic reimbursed pursuant to\nthis section shall not charge or seek any reimbursement from or have any\nrecourse against, an insured for the services provided pursuant to this\nsubparagraph, except for the collection of in-network copayments,\ncoinsurance, or deductibles for which the insured is responsible for\nunder the terms of the policy.\n (K) (i) This clause shall apply to outpatient treatment provided in a\nfacility issued an operating certificate by the commissioner of mental\nhealth pursuant to the provisions of article thirty-one of the mental\nhygiene law, or in a facility operated by the office of mental health,\nor in a crisis stabilization center licensed pursuant to section 36.01\nof the mental hygiene law, that is participating in the insurer's\nprovider network. Reimbursement for covered outpatient treatment\nprovided by such a facility shall be at rates negotiated between the\ninsurer and the participating facility, provided that such rates are not\nless than the rates that would be paid for such treatment pursuant to\nthe medical assistance program under title eleven of article five of the\nsocial services law. For the purposes of this clause, the rates that\nwould be paid for such treatment pursuant to the medical assistance\nprogram under title eleven of article five of the social services law\nshall be the rates with an effective date of April first of the\npreceding year, which shall be established prior to October first of the\npreceding calendar year.\n (ii) The office of mental health shall publish information adequate to\ncalculate the rates that would be paid for such treatment pursuant to\nthe medical assistance program under title eleven of article five of the\nsocial services law. Such information shall be provided in a form and\nmanner to be determined by the commissioner of mental health. Nothing in\nthis clause shall be construed to relieve an insurer of the obligation\nto reimburse at no less than the applicable minimum rate set forth in\nclause (i) of this subparagraph. Prior to the submission of premium rate\nfilings and applications, the superintendent shall provide insurers with\nguidance on factors to consider in calculating the impact of rate\nchanges for the purposes of submitting premium rate filings and\napplications to the superintendent for the subsequent policy year

no less than the applicable minimum rate set forth in\nclause (i) of this subparagraph. Prior to the submission of premium rate\nfilings and applications, the superintendent shall provide insurers with\nguidance on factors to consider in calculating the impact of rate\nchanges for the purposes of submitting premium rate filings and\napplications to the superintendent for the subsequent policy year. To\nthe extent that the rates with an effective date of April first differ\nfrom the estimated rates incorporated in premium rate filings and\napplications, insurers may account for such differences in future\npremium rate filings and applications submitted to the superintendent\nfor approval.\n (6) * (A) Every policy that provides hospital, major medical or\nsimilar comprehensive coverage shall provide inpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such inpatient coverage\nshall include unlimited medically necessary treatment for substance use\ndisorder treatment services provided in residential settings. Further,\nsuch inpatient coverage shall not apply financial requirements or\ntreatment limitations, including utilization review requirements, to\ninpatient substance use disorder benefits that are more restrictive than\nthe predominant financial requirements and treatment limitations applied\nto substantially all medical and surgical benefits covered by the\npolicy.\n * NB Effective until January 1, 2027\n * (A) Every policy that provides hospital, major medical or similar\ncomprehensive coverage shall provide inpatient coverage for the\ndiagnosis and treatment of substance-related and addictive disorder,\nincluding detoxification and rehabilitation services. Such inpatient\ncoverage shall include unlimited medically necessary treatment for\nsubstance-related and addictive disorder treatment services provided in\nresidential settings. Further, such inpatient coverage shall not apply\nfinancial requirements or treatment limitations, including utilization\nreview requirements, to inpatient substance-related and addictive\ndisorder benefits that are more restrictive than the predominant\nfinancial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the policy.\n * NB Effective January 1, 2027\n * (B) Coverage provided under this paragraph may be limited to\nfacilities in New York state that are licensed, certified or otherwise\nauthorized by the office of alcoholism and substance abuse services and,\nin other states, to those which are accredited by the joint commission\nas alcoholism, substance abuse or chemical dependence treatment programs\nand are similarly licensed, certified, or otherwise authorized in the\nstate in which the facility is located.\n * NB Effective until January 1, 2027\n * (B) Coverage provided under this paragraph may be limited to\nfacilities in New York state that are licensed, certified or otherwise\nauthorized by the office of addiction services and supports and, in\nother states, to those which are accredited by the joint commission as\nalcoholism, addiction, substance abuse or chemical dependence treatment\nprograms and are similarly licensed, certified, or otherwise authorized\nin the state in which the facility is located.\n * NB Effective January 1, 2027\n (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n * (D) This subparagraph shall apply to facilities in this state that\nare licensed, certified or otherwise authorized by the office of\nalcoholism and substance abuse services that are participating in the\ninsurer's provider network. Coverage provided under this paragraph shall\nnot be subject to preauthorization

that are consistent with those imposed on other benefits within a\ngiven policy.\n * (D) This subparagraph shall apply to facilities in this state that\nare licensed, certified or otherwise authorized by the office of\nalcoholism and substance abuse services that are participating in the\ninsurer's provider network. Coverage provided under this paragraph shall\nnot be subject to preauthorization. Coverage provided under this\nparagraph shall also not be subject to concurrent utilization review\nduring the first twenty-eight days of the inpatient admission provided\nthat the facility notifies the insurer of both the admission and the\ninitial treatment plan within two business days of the admission. The\nfacility shall perform daily clinical review of the patient, including\nperiodic consultation with the insurer at or just prior to the\nfourteenth day of treatment to ensure that the facility is using the\nevidence-based and peer reviewed clinical review tool utilized by the\ninsurer which is designated by the office of alcoholism and substance\nabuse services and appropriate to the age of the patient, to ensure that\nthe inpatient treatment is medically necessary for the patient. Prior to\ndischarge, the facility shall provide the patient and the insurer with a\nwritten discharge plan which shall describe arrangements for additional\nservices needed following discharge from the inpatient facility as\ndetermined using the evidence-based and peer-reviewed clinical review\ntool utilized by the insurer which is designated by the office of\nalcoholism and substance abuse services. Prior to discharge, the\nfacility shall indicate to the insurer whether services included in the\ndischarge plan are secured or determined to be reasonably available. Any\nutilization review of treatment provided under this subparagraph may\ninclude a review of all services provided during such inpatient\ntreatment, including all services provided during the first twenty-eight\ndays of such inpatient treatment. Provided, however, the insurer shall\nonly deny coverage for any portion of the initial twenty-eight day\ninpatient treatment on the basis that such treatment was not medically\nnecessary if such inpatient treatment was contrary to the evidence-based\nand peer reviewed clinical review tool utilized by the insurer which is\ndesignated by the office of alcoholism and substance abuse services. An\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n * NB Effective until January 1, 2027\n * (D) This subparagraph shall apply to facilities in this state that\nare licensed, certified or otherwise authorized by the office of\naddiction services and supports that are participating in the insurer's\nprovider network. Coverage provided under this paragraph shall not be\nsubject to preauthorization. Coverage provided under this paragraph\nshall also not be subject to concurrent utilization review during the\nfirst twenty-eight days of the inpatient admission provided that the\nfacility notifies the insurer of both the admission and the initial\ntreatment plan within two business days of the admission. The facility\nshall perform daily clinical review of the patient, including periodic\nconsultation with the insurer at or just prior to the fourteenth day of\ntreatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports and\nappropriate to the age of the patient, to ensure that the inpatient\ntreatment is medically necessary for the patient

dic\nconsultation with the insurer at or just prior to the fourteenth day of\ntreatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports and\nappropriate to the age of the patient, to ensure that the inpatient\ntreatment is medically necessary for the patient. Prior to discharge,\nthe facility shall provide the patient and the insurer with a written\ndischarge plan which shall describe arrangements for additional services\nneeded following discharge from the inpatient facility as determined\nusing the evidence-based and peer-reviewed clinical review tool utilized\nby the insurer which is designated by the office of addiction services\nand supports. Prior to discharge, the facility shall indicate to the\ninsurer whether services included in the discharge plan are secured or\ndetermined to be reasonably available. Any utilization review of\ntreatment provided under this subparagraph may include a review of all\nservices provided during such inpatient treatment, including all\nservices provided during the first twenty-eight days of such inpatient\ntreatment. Provided, however, the insurer shall only deny coverage for\nany portion of the initial twenty-eight day inpatient treatment on the\nbasis that such treatment was not medically necessary if such inpatient\ntreatment was contrary to the evidence-based and peer reviewed clinical\nreview tool utilized by the insurer which is designated by the office of\naddiction services and supports. An insured shall not have any financial\nobligation to the facility for any treatment under this subparagraph\nother than any copayment, coinsurance, or deductible otherwise required\nunder the policy.\n * NB Effective January 1, 2027\n * (E) The criteria for medical necessity determinations under the\npolicy with respect to inpatient substance use disorder benefits shall\nbe made available by the insurer to any insured, prospective insured, or\nin-network provider upon request.\n * NB Effective until January 1, 2027\n * (E) The criteria for medical necessity determinations under the\npolicy with respect to inpatient substance-related and addictive\ndisorder benefits shall be made available by the insurer to any insured,\nprospective insured, or in-network provider upon request.\n * NB Effective January 1, 2027\n * (F) For purposes of this paragraph:\n (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n (iv) "substance use disorder" shall have the meaning set forth in the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders or the most recent edition of another generally recognized\nindependent standard of current medical practice such as the\ninternational classification of diseases.\n * NB Effective until January 1, 2027\n

rvices provided under the\npolicy; and\n (iv) "substance use disorder" shall have the meaning set forth in the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders or the most recent edition of another generally recognized\nindependent standard of current medical practice such as the\ninternational classification of diseases.\n * NB Effective until January 1, 2027\n * (F) For purposes of this paragraph:\n (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n (iv) "substance-related and addictive disorder" shall have the meaning\nset forth in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n * NB Effective January 1, 2027\n (G) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n * (7) (A) Every policy that provides medical, major medical or similar\ncomprehensive-type coverage shall provide outpatient coverage for the\ndiagnosis and treatment of substance use disorder, including\ndetoxification and rehabilitation services. Such coverage shall not\napply financial requirements or treatment limitations to outpatient\nsubstance use disorder benefits that are more restrictive than the\npredominant financial requirements and treatment limitations applied to\nsubstantially all medical and surgical benefits covered by the policy.\n (B) Coverage under this paragraph may be limited to facilities in this\nstate that are licensed, certified or otherwise authorized by the office\nof addiction services and supports to provide outpatient substance use\ndisorder services and crisis stabilization centers licensed pursuant to\nsection 36.01 of the mental hygiene law, and, in other states, to those\nwhich are accredited by the joint commission as alcoholism or chemical\ndependence treatment programs and similarly licensed, certified or\notherwise authorized in the state in which the facility is located.\n (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n (C-1) A large group policy that provides coverage under this paragraph\nshall not impose copayments or coinsurance for outpatient substance use\ndisorder services that exceeds the copayment or coinsurance imposed for\na primary care office visit

bles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n (C-1) A large group policy that provides coverage under this paragraph\nshall not impose copayments or coinsurance for outpatient substance use\ndisorder services that exceeds the copayment or coinsurance imposed for\na primary care office visit. Provided that no greater than one such\ncopayment may be imposed for all services provided in a single day by a\nfacility licensed, certified or otherwise authorized by the office of\nalcoholism and substance abuse services to provide outpatient substance\nuse disorder services.\n (D) A policy providing coverage for substance use disorder services\npursuant to this paragraph shall provide up to twenty outpatient visits\nper policy or calendar year to an individual who identifies him or\nherself as a family member of a person suffering from substance use\ndisorder and who seeks treatment as a family member who is otherwise\ncovered by the applicable policy pursuant to this paragraph. The\ncoverage required by this paragraph shall include treatment as a family\nmember pursuant to such family member's own policy provided such family\nmember:\n (i) does not exceed the allowable number of family visits provided by\nthe applicable policy pursuant to this paragraph; and\n (ii) is otherwise entitled to coverage pursuant to this paragraph and\nsuch family member's applicable policy.\n (E) This subparagraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of alcoholism\nand substance abuse services for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Coverage provided under\nthis paragraph shall not be subject to preauthorization. Coverage\nprovided under this paragraph shall not be subject to concurrent review\nfor the first four weeks of continuous treatment, not to exceed\ntwenty-eight visits, provided the facility notifies the insurer of both\nthe start of treatment and the initial treatment plan within two\nbusiness days. The facility shall perform clinical assessment of the\npatient at each visit, including periodic consultation with the insurer\nat or just prior to the fourteenth day of treatment to ensure that the\nfacility is using the evidence-based and peer reviewed clinical review\ntool utilized by the insurer which is designated by the office of\nalcoholism and substance abuse services and appropriate to the age of\nthe patient, to ensure that the outpatient treatment is medically\nnecessary for the patient. Any utilization review of the treatment\nprovided under this subparagraph may include a review of all services\nprovided during such outpatient treatment, including all services\nprovided during the first four weeks of continuous treatment, not to\nexceed twenty-eight visits, of such outpatient treatment. Provided,\nhowever, the insurer shall only deny coverage for any portion of the\ninitial four weeks of continuous treatment, not to exceed twenty-eight\nvisits, for outpatient treatment on the basis that such treatment was\nnot medically necessary if such outpatient treatment was contrary to the\nevidence-based and peer reviewed clinical review tool utilized by the\ninsurer which is designated by the office of alcoholism and substance\nabuse services

ge for any portion of the\ninitial four weeks of continuous treatment, not to exceed twenty-eight\nvisits, for outpatient treatment on the basis that such treatment was\nnot medically necessary if such outpatient treatment was contrary to the\nevidence-based and peer reviewed clinical review tool utilized by the\ninsurer which is designated by the office of alcoholism and substance\nabuse services. An insured shall not have any financial obligation to\nthe facility for any treatment under this subparagraph other than any\ncopayment, coinsurance, or deductible otherwise required under the\npolicy.\n (F) The criteria for medical necessity determinations under the policy\nwith respect to outpatient substance use disorder benefits shall be made\navailable by the insurer to any insured, prospective insured, or\nin-network provider upon request.\n (G) For purposes of this paragraph:\n (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n (iv) "substance use disorder" shall have the meaning set forth in the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders or the most recent edition of another generally recognized\nindependent standard of current medical practice such as the\ninternational classification of diseases.\n (H) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n (I) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n (J) (i) This clause shall apply to facilities in this state that are\nlicensed, certified, or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law

cipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law. For the\npurposes of this clause, the rates that would be paid for such treatment\npursuant to the medical assistance program under title eleven of article\nfive of the social services law shall be the rates with an effective\ndate of April first of the preceding year, which shall be established\nprior to October first of the preceding calendar year.\n (ii) The office of addiction services and supports shall publish\ninformation adequate to calculate the rates that would be paid for such\ntreatment pursuant to the medical assistance program under title eleven\nof article five of the social services law. Such information shall be\nprovided in a form and manner to be determined by the commissioner of\naddiction services and supports. Nothing in this clause shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in clause (i) of this\nsubparagraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide insurers with guidance on\nfactors to consider in calculating the impact of rate changes for the\npurposes of submitting premium rate filings and applications to the\nsuperintendent for the subsequent policy year. To the extent that the\nrates with an effective date of April first differ from the estimated\nrates incorporated in premium rate filings and applications, insurers\nmay account for such differences in future premium rate filings and\napplications submitted to the superintendent for approval.\n * NB Effective until January 1, 2027\n * (7) (A) Every policy that provides medical, major medical or similar\ncomprehensive-type coverage shall provide outpatient coverage for the\ndiagnosis and treatment of substance-related and addictive disorder,\nincluding detoxification and rehabilitation services. Such coverage\nshall not apply financial requirements or treatment limitations to\noutpatient substance-related and addictive disorder benefits that are\nmore restrictive than the predominant financial requirements and\ntreatment limitations applied to substantially all medical and surgical\nbenefits covered by the policy.\n (B) Coverage under this paragraph may be limited to facilities in this\nstate that are licensed, certified or otherwise authorized by the office\nof addiction services and supports to provide outpatient\nsubstance-related and addictive disorder services and crisis\nstabilization centers licensed pursuant to section 36.01 of the mental\nhygiene law, and, in other states, to those which are accredited by the\njoint commission as alcoholism, addiction or chemical dependence\ntreatment programs and similarly licensed, certified or otherwise\nauthorized in the state in which the facility is located.\n (C) Coverage provided under this paragraph may be subject to annual\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven policy.\n (C-1) A large group policy that provides coverage under this paragraph\nshall not impose copayments or coinsurance for outpatient\nsubstance-related and addictive disorder services that exceeds the\ncopayment or coinsurance imposed for a primary care office visit.\nProvided that no greater than one such copayment may be imposed for all\nservices provided in a single day by a facility licensed, certified or\notherwise authorized by the office of addiction services and supports to\nprovide outpatient substance-related and addictive disorder services.\n (D) A policy providing cove

exceeds the\ncopayment or coinsurance imposed for a primary care office visit.\nProvided that no greater than one such copayment may be imposed for all\nservices provided in a single day by a facility licensed, certified or\notherwise authorized by the office of addiction services and supports to\nprovide outpatient substance-related and addictive disorder services.\n (D) A policy providing coverage for substance-related and addictive\ndisorder services pursuant to this paragraph shall provide up to twenty\noutpatient visits per policy or calendar year to an individual who\nidentifies themselves as a family member of a person suffering from a\nsubstance-related and addictive disorder and who seeks treatment as a\nfamily member who is otherwise covered by the applicable policy pursuant\nto this paragraph. The coverage required by this paragraph shall include\ntreatment as a family member pursuant to such family member's own policy\nprovided such family member:\n (i) does not exceed the allowable number of family visits provided by\nthe applicable policy pursuant to this paragraph; and\n (ii) is otherwise entitled to coverage pursuant to this paragraph and\nsuch family member's applicable policy.\n (E) This subparagraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Coverage provided under\nthis paragraph shall not be subject to preauthorization. Coverage\nprovided under this paragraph shall not be subject to concurrent review\nfor the first four weeks of continuous treatment, not to exceed\ntwenty-eight visits, provided the facility notifies the insurer of both\nthe start of treatment and the initial treatment plan within two\nbusiness days. The facility shall perform clinical assessment of the\npatient at each visit, including periodic consultation with the insurer\nat or just prior to the fourteenth day of treatment to ensure that the\nfacility is using the evidence-based and peer reviewed clinical review\ntool utilized by the insurer which is designated by the office of\naddiction services and supports and appropriate to the age of the\npatient, to ensure that the outpatient treatment is medically necessary\nfor the patient. Any utilization review of the treatment provided under\nthis subparagraph may include a review of all services provided during\nsuch outpatient treatment, including all services provided during the\nfirst four weeks of continuous treatment, not to exceed twenty-eight\nvisits, of such outpatient treatment. Provided, however, the insurer\nshall only deny coverage for any portion of the initial four weeks of\ncontinuous treatment, not to exceed twenty-eight visits, for outpatient\ntreatment on the basis that such treatment was not medically necessary\nif such outpatient treatment was contrary to the evidence-based and peer\nreviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports

ny coverage for any portion of the initial four weeks of\ncontinuous treatment, not to exceed twenty-eight visits, for outpatient\ntreatment on the basis that such treatment was not medically necessary\nif such outpatient treatment was contrary to the evidence-based and peer\nreviewed clinical review tool utilized by the insurer which is\ndesignated by the office of addiction services and supports. An insured\nshall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n (F) The criteria for medical necessity determinations under the policy\nwith respect to outpatient substance-related and addictive disorder\nbenefits shall be made available by the insurer to any insured,\nprospective insured, or in-network provider upon request.\n (G) For purposes of this paragraph:\n (i) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (ii) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (iii) "treatment limitation" means limits on the frequency of\ntreatment, number of visits, days of coverage, or other similar limits\non the scope or duration of treatment and includes nonquantitative\ntreatment limitations such as: medical management standards limiting or\nexcluding benefits based on medical necessity, or based on whether the\ntreatment is experimental or investigational; formulary design for\nprescription drugs; network tier design; standards for provider\nadmission to participate in a network, including reimbursement rates;\nmethods for determining usual, customary, and reasonable charges;\nfail-first or step therapy protocols; exclusions based on failure to\ncomplete a course of treatment; and restrictions based on geographic\nlocation, facility type, provider specialty, and other criteria that\nlimit the scope or duration of benefits for services provided under the\npolicy; and\n (iv) "substance-related and addictive disorder" shall have the meaning\nset forth in the most recent edition of the diagnostic and statistical\nmanual of mental disorders or the most recent edition of another\ngenerally recognized independent standard of current medical practice\nsuch as the international classification of diseases.\n (H) An insurer shall provide coverage under this paragraph, at a\nminimum, consistent with the federal Paul Wellstone and Pete Domenici\nMental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §\n1185a).\n (I) This subparagraph shall apply to crisis stabilization centers in\nthis state that are licensed pursuant to section 36.01 of the mental\nhygiene law and participate in the insurer's provider network. Benefits\nfor care in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this subparagraph may be\nreviewed retrospectively. Where care is denied retrospectively, an\ninsured shall not have any financial obligation to the facility for any\ntreatment under this subparagraph other than any copayment, coinsurance,\nor deductible otherwise required under the policy.\n (J) (i) This clause shall apply to facilities in this state that are\nlicensed, certified, or otherwise authorized by the office of addiction\nservices and supports for the provision of outpatient, intensive\noutpatient, outpatient rehabilitation and opioid treatment that are\nparticipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law

cipating in the insurer's provider network. Reimbursement for\ncovered outpatient treatment provided by such facilities shall be at\nrates negotiated between the insurer and the participating facility,\nprovided that such rates are not less than the rates that would be paid\nfor such treatment pursuant to the medical assistance program under\ntitle eleven of article five of the social services law. For the\npurposes of this clause, the rates that would be paid for such treatment\npursuant to the medical assistance program under title eleven of article\nfive of the social services law shall be the rates with an effective\ndate of April first of the preceding year, which shall be established\nprior to October first of the preceding calendar year.\n (ii) The office of addiction services and supports shall publish\ninformation adequate to calculate the rates that would be paid for such\ntreatment pursuant to the medical assistance program under title eleven\nof article five of the social services law. Such information shall be\nprovided in a form and manner to be determined by the commissioner of\naddiction services and supports. Nothing in this clause shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in clause (i) of this\nsubparagraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide insurers with guidance on\nfactors to consider in calculating the impact of rate changes for the\npurposes of submitting premium rate filings and applications to the\nsuperintendent for the subsequent policy year. To the extent that the\nrates with an effective date of April first differ from the estimated\nrates incorporated in premium rate filings and applications, insurers\nmay account for such differences in future premium rate filings and\napplications submitted to the superintendent for approval.\n * NB Effective January 1, 2027\n (7-a) * (A) No policy that provides medical, major medical or similar\ncomprehensive-type small group coverage and provides coverage for\nprescription drugs for medication for the treatment of a substance use\ndisorder shall require prior authorization for an initial or renewal\nprescription for the detoxification or maintenance treatment of a\nsubstance use disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law. Every policy that provides medical, major medical or\nsimilar comprehensive-type large group coverage shall provide coverage\nfor prescription drugs for medication for the treatment of a substance\nuse disorder and shall not require prior authorization for an initial or\nrenewal prescription for the detoxification or maintenance treatment of\na substance use disorder, including all buprenorphine products,\nmethadone, long acting injectable naltrexone, or medication for opioid\noverdose reversal prescribed or dispensed to an insured covered under\nthe policy, including federal food and drug administration-approved\nover-the-counter opioid overdose reversal medication as prescribed,\ndispensed or as otherwise authorized under state or federal law, except\nwhere otherwise prohibited by law.\n * NB Effective until January 1, 2027\n * (A) No policy that provides medical, major medical or similar\ncomprehensive-type small group coverage and provides coverage for\nprescription drugs for medication for the treatment of a\nsubstance-related and addictive disorder shall require prior\nauthorization for an initial or renewal prescription for the\ndetoxification or maintenance treatment of a substance-related and\

January 1, 2027\n * (A) No policy that provides medical, major medical or similar\ncomprehensive-type small group coverage and provides coverage for\nprescription drugs for medication for the treatment of a\nsubstance-related and addictive disorder shall require prior\nauthorization for an initial or renewal prescription for the\ndetoxification or maintenance treatment of a substance-related and\naddictive disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law. Every policy that provides medical, major medical or\nsimilar comprehensive-type large group coverage shall provide coverage\nfor prescription drugs for medication for the treatment of a\nsubstance-related and addictive disorder and shall not require prior\nauthorization for an initial or renewal prescription for the\ndetoxification or maintenance treatment of a substance-related and\naddictive disorder, including all buprenorphine products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the policy,\nincluding federal food and drug administration-approved over-the-counter\nopioid overdose reversal medication as prescribed, dispensed or as\notherwise authorized under state or federal law, except where otherwise\nprohibited by law.\n * NB Effective January 1, 2027\n (B) Coverage provided under this paragraph may be subject to\ncopayments, coinsurance, and annual deductibles that are consistent with\nthose imposed on other benefits within the policy.\n (7-b) Every policy that provides coverage for treatment at an opioid\ntreatment program shall not impose a co-payment fee during the course of\ntreatment on any insured for such treatment. For the purposes of this\nsection "opioid treatment program" means a program or practitioner\nengaged in opioid treatment of individuals with an opioid agonist\ntreatment medication.\n (8) (A) Every insurer issuing a group policy for delivery in this\nstate that provides medical, major-medical or similar comprehensive-type\ncoverage shall provide coverage for the provision of preventive and\nprimary care services.\n (B) In subparagraphs (A), (C) and (D) of this paragraph, preventive\nand primary care services means the following services rendered to a\ncovered child of an insured from the date of birth through the\nattainment of nineteen years of age:\n (i) an initial hospital check-up and well-child visits scheduled in\naccordance with the prevailing clinical standards of a national\nassociation of pediatric physicians designated by the commissioner of\nhealth (except for any standard that would limit the specialty or forum\nof licensure of the practitioner providing the service other than the\nlimits under state law). Coverage for such services rendered shall be\nprovided only to the extent that such services are provided by or under\nthe supervision of a physician, or other professional licensed under\narticle one hundred thirty-nine of the education law whose scope of\npractice pursuant to such law includes the authority to provide the\nspecified services

g the service other than the\nlimits under state law). Coverag

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