Benefits

§ 4303. Benefits. (a) Every contract issued by a hospital service\ncorporation or health service corporation which provides coverage for\nin-patient hospital care shall also provide coverage:\n (1) For preadmission testing performed in hospital facilities prior to\nscheduled surgery. A patient who uses the out-patient facilities of a\nhospital shall be entitled to benefits for tests ordered by a physician\nwhich are performed as a planned preliminary to admission of the patient\nas an in-patient for surgery in the same hospital, provided that:\n (A) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed,\n (B) reservations for a hospital bed and for an operating room shall\nhave been made prior to the performance of the tests,\n (C) surgery actually takes place within seven days of such presurgical\ntests, and\n (D) the patient is physically present at the hospital for the tests.\n (2) (A) For services to treat an emergency condition in hospital\nfacilities:\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 contract subject to this\nparagraph.\n (C) For the purpose of this provision, "emergency condition" means a\nmedical or behavioral condition that manifests itself by acute symptoms\nof sufficient 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) For the purpose of this provision, "emergency services" means,\nwith respect to an emergency condition: (i) a medical screening\nexamination as required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, which is within the capability of the emergency\ndepartment of a hospital, including ancillary services routinely\navailable to the emergency department to evaluate such emergency medical\ncondition; and (ii) within the capabilities of the staff and facilities\navailable at the hospital, such further medical examination and\ntreatment as are required under section 1867 of the Social Security Act,\n42 U.S.C

within the capability of the emergency\ndepartment of a hospital, including ancillary services routinely\navailable to the emergency department to evaluate such emergency medical\ncondition; and (ii) within the capabilities of the staff and facilities\navailable at the hospital, such further medical examination and\ntreatment as are required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, to stabilize the patient.\n (E) For the purpose of this provision, "to stabilize" means, with\nrespect to an emergency condition, to provide such medical treatment of\nthe condition as may be necessary to assure, within reasonable medical\nprobability, that no material deterioration of the condition is likely\nto result from or occur during the transfer of the subscriber from a\nfacility or to deliver a newborn child (including the placenta).\n (3) For home care to residents in this state. Such home care coverage\nshall be included at the inception of all new contracts and, with\nrespect to all other contracts, added at any anniversary date of the\ncontract subject to evidence of insurability. Such coverage may be\nsubject to an annual deductible of not more than fifty dollars for each\ncovered person and may be subject to a coinsurance provision which\nprovides for coverage of not less than seventy-five percent of the\nreasonable cost of services for which payment may be made. No such\ncorporation need provide such coverage to persons eligible for medicare.\n (A) Home care shall mean the care and treatment of a covered person\nwho is under the care of a physician but only if:\n (i) hospitalization or confinement in a nursing facility as defined in\nsubchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq,\nwould otherwise have been required if home care was not provided, and\n (ii) the plan covering the home health service is established and\napproved in writing by such physician.\n (B) 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.\n (C) Home care shall consist of one or more of the following:\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, and\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 or provided under the contract if the\ncovered person had been hospitalized or confined in a skilled nursing\nfacility as defined in subchapter XVIII of the Social Security Act, 42\nU.S.C. § 1395 et seq.\n (D) 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 covered person. Four hours of home health\naide service shall be considered as one home care visit. Every contract\nissued by a hospital service corporation or health service corporation\nwhich provides coverage supplementing part A and part B of subchapter\nXVIII of the Social Security Act, 42 U.S.C

han forty such visits in any calendar year or in any continuous period\nof twelve months, for each covered person. Four hours of home health\naide service shall be considered as one home care visit. Every contract\nissued by a hospital service corporation or health service corporation\nwhich provides coverage supplementing part A and part B of subchapter\nXVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make\navailable and, if requested by a subscriber holding a direct payment\ncontract or by all subscribers in a group remittance group or by the\ncontract holder in the case of group contracts issued pursuant to\nsection four thousand three hundred five of this article, provide\ncoverage of supplemental home care visits beyond those provided by part\nA and part B, sufficient to produce an aggregate coverage of three\nhundred sixty-five home care visits per contract year. Such coverage\nshall be provided pursuant to regulations prescribed by the\nsuperintendent. Written notice of the availability of such coverage\nshall be delivered to the group remitting agent or group contract holder\nprior to inception of such contract and annually thereafter, except that\nthis notice shall not be required where a policy covers two hundred or\nmore employees or where the benefit structure was the subject of\ncollective bargaining affecting persons who are employed in more than\none state.\n The provisions of this subsection shall not apply to a contract issued\npursuant to section four thousand three hundred five of this article\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 (b) Every contract issued by a medical expense indemnity corporation\nor a health service corporation which provides coverage for in-patient\nsurgical care shall include coverage for a second surgical opinion by a\nqualified physician on the need for surgery, except that this provision\nshall not apply to a contract issued pursuant to section four thousand\nthree hundred five of this article which covers persons employed in more\nthan one state or the benefit structure of which was the subject of\ncollective bargaining affecting persons who are employed in more than\none state.\n (c) (1) (A) Every contract issued by a corporation subject to the\nprovisions of this article which provides hospital service, medical\nexpense indemnity or both shall provide coverage for maternity care\nincluding hospital, surgical or medical care to the same extent that\nhospital service, medical expense indemnity or both are provided for\nillness or disease under the contract. Such maternity care coverage,\nother than coverage for perinatal complications, shall include inpatient\nhospital coverage for mother and for newborn for at least forty-eight\nhours after childbirth for any delivery other than a caesarean section,\nand for at least ninety-six hours following a caesarean section. Such\ncoverage for maternity care shall include the services of a midwife\nlicensed pursuant to article one hundred forty of the education law,\npracticing consistent with section sixty-nine hundred fifty-one of the\neducation law and affiliated or practicing in conjunction with a\nfacility licensed pursuant to article twenty-eight of the public health\nlaw, but no insurer shall be required to pay for duplicative routine\nservices actually provided by both a licensed midwife and a physician.\n (B) Maternity care coverage also shall 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 (C) The mother shall have the option to be discharged earlier than the\ntime periods established in subparagraph (A) of this paragraph

ed by both a licensed midwife and a physician.\n (B) Maternity care coverage also shall 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 (C) The mother shall have the option to be discharged earlier than the\ntime periods established in subparagraph (A) of this paragraph. 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 contract. The contract\nmust cover 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\ncontract and subject to the provisions of this paragraph, and not\nsubject to deductibles, coinsurance or copayments.\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 (2) Coverage provided under this subsection 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 (c-1) Any contract issued by a medical expense indemnity corporation,\na hospital service corporation or a health services corporation that\nprovides medical, major medical, or similar comprehensive-type coverage\nshall provide coverage for prenatal vitamins when prescribed by a health\ncare practitioner licensed, certified, or authorized under title eight\nof the education law, and acting within their lawful scope of practice.\n (d) (1) A hospital service corporation or a health service corporation\nwhich provides coverage for in-patient hospital care must make available\nand, if requested by a person holding a direct payment individual\ncontract or by all persons holding individual contracts in a group whose\npremiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide coverage for care in nursing\nhomes. Such coverage shall be made available at the inception of all new\ncontracts and, with respect to all other contracts, at any anniversary\ndate subject to evidence of insurability

premiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide coverage for care in nursing\nhomes. Such coverage shall be made available at the inception of all new\ncontracts and, with respect to all other contracts, at any anniversary\ndate subject to evidence of insurability. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (2) For the purpose of this subsection, care in nursing homes shall\nmean the continued care and treatment of a covered person who is under\nthe care of a physician but only if (i) the care is provided in a\nnursing home as defined in section two thousand eight hundred one of the\npublic health law or a skilled nursing facility as defined in subchapter\nXVIII of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii)\nthe 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 (iii) further hospitalization would otherwise be\nnecessary. The aggregate of the number of covered days of care in a\nhospital and the number of covered days of care in a nursing home, with\ntwo days of care in a nursing home equivalent to one day of care in a\nhospital, need not exceed the number of covered days of hospital care\nprovided under the contract in a benefit period. The level of benefits\nto be provided for nursing home care must be reasonably related to the\nbenefits provided for hospital care.\n (e) (1) A hospital service corporation or a health service corporation\nwhich provides coverage for in-patient hospital care must make available\nand, if requested by a person holding a direct payment individual\ncontract or by all persons holding individual contracts in a group whose\npremiums are paid by a remitting agent or by the contract holder in the\ncase of a group contract issued pursuant to section four thousand three\nhundred five of this article, provide coverage for ambulatory care in\nhospital out-patient facilities, as a hospital is defined in section two\nthousand eight hundred one of the public health law, or subchapter XVIII\nof the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of\nthe availability of such coverage shall be delivered to the group\nremitting agent or group contract holder prior to inception of such\ncontract 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 (2) For the purpose of this subsection, ambulatory care in hospital\nout-patient facilities shall mean services for diagnostic x-rays,\nlaboratory and pathological examinations, physical and occupational\ntherapy and radiation therapy, and services and medications used for\nnonexperimental cancer chemotherapy and cancer hormone therapy, provided\nthat such services and medications are (i) related to and necessary for\nthe treatment or diagnosis of the patient's illness or injury, (ii)\nordered by a physician and (iii) in the case of physical therapy,\nservices are to be furnished in connection with the same illness for\nwhich the patient had been hospitalized or in connection with surgical\ncare, but in no event need benefits for physical therapy be provided\nwhich commences more than six months after discharge from a hospital or\nthe date surgical care was rendered, and in no event need benefits for\nphysical therapy be provi

hysical therapy,\nservices are to be furnished in connection with the same illness for\nwhich the patient had been hospitalized or in connection with surgical\ncare, but in no event need benefits for physical therapy be provided\nwhich commences more than six months after discharge from a hospital or\nthe date surgical care was rendered, and in no event need benefits for\nphysical therapy be provided after three hundred sixty-five days from\nthe date of discharge from a hospital or the date surgical care was\nrendered. Such coverage shall be made available at the inception of all\nnew contracts and, with respect to all other contracts, at any\nanniversary date subject to evidence of insurability.\n (f) (1) A medical expense indemnity corporation or a health service\ncorporation which provides coverage for physicians' services must make\navailable and, if requested by a person holding an individual direct\npayment contract or by all persons holding individual contracts in a\ngroup whose premiums are paid by a remitting agent or by the contract\nholder in the case of a group contract issued pursuant to section four\nthousand three hundred five of this article, provide coverage for\nambulatory care in physicians' offices. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (2) For the purpose of this subsection, ambulatory care in physicians'\noffices shall mean services for diagnostic x-rays, radiation therapy,\nlaboratory and pathological examinations, and services and medications\nused for nonexperimental cancer chemotherapy and cancer hormone therapy,\nprovided that such services and medications are (i) related to and\nnecessary for the treatment or diagnosis of the patient's illness or\ninjury, and (ii) ordered by a physician. Such coverage shall be made\navailable at the inception of all new contracts and, with respect to all\nother contracts at any anniversary date subject to evidence of\ninsurability.\n (g) A medical expense indemnity corporation, hospital service\ncorporation or a health service corporation, that provides group, group\nremittance or school blanket coverage for inpatient hospital care or\ncoverage for physician services shall provide as part of its contract\ncoverage for the diagnosis and treatment of mental health conditions\nand:\n * (1) where the contract provides coverage for inpatient hospital\ncare, benefits for in-patient care in a hospital as defined by\nsubdivision ten of section 1.03 of the mental hygiene law or for\ninpatient care provided in other states, to similarly licensed\nhospitals, and benefits for out-patient care provided in a facility\nissued an operating certificate by the commissioner of mental health\npursuant to the provisions of article thirty-one of the mental hygiene\nlaw or in a facility operated by the office of mental health or in a\ncrisis stabilization center licensed pursuant to section 36.01 of the\nmental hygiene law or for out-patient care provided in other states, to\nsimilarly certified facilities; and\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (1) where the contract provides coverage for inpatient hospital\ncare, benefits for: in-patient care in a hospital as defined by\nsubdivision ten of section 1.03 of the mental hygiene law; sub-acute\ncare in a residential facility licensed or operated by the office of\nmental health; outpatient care provided by a facility issued an\noperating certificate by the commissioner of mental health pursuant to\nthe provisions of article thirty-one of the mental hygiene law

benefits for: in-patient care in a hospital as defined by\nsubdivision ten of section 1.03 of the mental hygiene law; sub-acute\ncare in a residential facility licensed or operated by the office of\nmental health; outpatient care provided by a facility issued an\noperating certificate by the commissioner of mental health pursuant to\nthe provisions 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 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 (2) where the contract provides coverage for physician services such\ncontract shall provide benefits for outpatient care provided by a\npsychiatrist or psychologist licensed to practice in this state, or a\nmental health counselor, marriage and family therapist, or psychoanalyst\nlicensed pursuant to article one hundred sixty-three of the education\nlaw, or a licensed clinical social worker within the lawful scope of his\nor her practice, who is licensed pursuant to article one hundred\nfifty-four of the education law, a nurse practitioner licensed to\npractice in this state, or professional corporation or university\nfaculty practice corporation thereof. Nothing herein shall be construed\nto modify or expand the scope of practice of a mental health counselor,\nmarriage and family therapist, or psychoanalyst licensed pursuant to\narticle one hundred sixty-three of the education law. Further, nothing\nherein shall be construed to create a new mandated health benefit.\n (3) Such coverage may be subject to annual deductibles, co-pays and\ncoinsurance as may be deemed appropriate by the superintendent and shall\nbe consistent with those imposed on other benefits under the contract.\nProvided that no copayment or coinsurance imposed for outpatient mental\nhealth services provided in a facility licensed, certified or otherwise\nauthorized by the office of mental health shall exceed the copayments or\ncoinsurance imposed for a primary care office visit under the contract.\n (4) Coverage under this subsection 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 contract.\n (5) The criteria for medical necessity determinations under the\ncontract with respect to mental health benefits shall be made available\nby the corporation to any insured, prospective insured, or in-network\nprovider upon request.\n (6) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n * (C) "treatment limitation" means limits on the

spective insured, or in-network\nprovider upon request.\n (6) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n * (C) "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\ncontract; and\n * NB Effective until after the superintendent of financial services\nand the commissioner of health have promulgated regulations\n * (C) "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\ncontract;\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (D) "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 * (D) "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 * (E) "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 * (F) "critical time intervention services" means services rendered by\na provider licensed under article thirty-one of the mental hyg

ocations 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 * (F) "critical time intervention services" means services rendered by\na provider licensed under article thirty-one of the mental hygiene law\nthat 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 stabilized; and\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n * (G) "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 (7) A corporation shall provide coverage under this subsection, 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 (8) This paragraph 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 corporation's provider\nnetwork. Where the contract provides coverage for inpatient hospital\ncare, benefits for inpatient hospital care in a hospital as defined by\nsubdivision ten of section 1.03 of the mental hygiene law and benefits\nfor sub-acute care in a crisis residence facility licensed or operated\nby the office of mental health shall not be subject to preauthorization.\nCoverage provided under this paragraph shall also not be subject to\nconcurrent utilization review for individuals who have not attained the\nage of eighteen during the first fourteen days of the inpatient\nadmission, provided the facility notifies the corporation of both the\nadmission and the initial treatment plan within two business days of the\nadmission, performs daily clinical review of the insured, and\nparticipates in periodic consultation with the corporation to ensure\nthat the facility is using the evidence-based and peer reviewed clinical\nreview criteria utilized by the corporation which is approved by the\noffice of mental health and appropriate to the age of the insured, to\nensure that the inpatient care is medically necessary for the insured.\nFor individuals who have attained age eighteen, coverage provided under\nthis paragraph shall also not be subject to concurrent review during the\nfirst thirty days of the inpatient or residential admission, provided\nthe facility notifies the corporation 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 corporation to ensure that the facility\nis using the evidence-based and peer reviewed clinical review criteria\nutilized by the corporation which is approved by the office of mental\nhealth and appropriate to the age of the insured, to ensure that the\ninpatient or residential care is medically necessary for the insured.\nHowever, concurrent review may be performed during the first thirty days\nif an insured meets clinical criteria designated by the office of mental\nhealth or where the insured is admitted to a hospital or facility which\nhas been designated by the office of mental health for concurrent\nreview, in consu

red, to ensure that the\ninpatient or residential care is medically necessary for the insured.\nHowever, concurrent review may be performed during the first thirty days\nif an insured meets clinical criteria designated by the office of mental\nhealth or where the insured is admitted to a hospital or facility which\nhas been designated by the office of mental health for concurrent\nreview, in consultation with the commissioner of health and the\nsuperintendent. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or\ndeductible otherwise required under the contract.\n (9) This paragraph shall apply to crisis stabilization centers in this\nstate that are licensed pursuant to section 36.01 of the mental hygiene\nlaw and participate in the corporation's provider network. Benefits for\ncare by a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or\ndeductible otherwise required under the contract.\n * (10) This paragraph 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 paragraph, "mobile crisis intervention services" means\nmental health and substance use disorder services, consisting of: (1)\ntelephonic 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 (A) 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 paragraph shall\nprevent services provided subsequent to the provision of mobile crisis\nintervention services from being subject to preauthorization.\n (B) 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 (C) If the covered services are provided by a non-participating mobile\ncrisis intervention services provider, a corporation shall not impose\nany administrative requirement or limitation on coverage that is more\nrestrictive than the requirements or limitations that apply to covered\nservices received from a participating mobile crisis intervention\nservices provider.\n (D) If the covered services are provided by a non-participating mobile\ncrisis 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 (E) 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 th

by a participating mobile crisis\nintervention services provider.\n (E) 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 contract.\n * NB Effective after the superintendent of financial services and the\ncommissioner of health have promulgated regulations\n (11) This paragraph shall apply to school-based mental health clinics\nthat are licensed pursuant to article thirty-one of the mental hygiene\nlaw and provide outpatient care in pre-school, elementary, or secondary\nschools. A corporation 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\ncorporation and school-based mental health clinic or, in the absence of\na negotiated rate, an amount no less than the rate that would be paid\nfor such services pursuant to the medical assistance program under title\neleven of article five of the social services law. Payment by a\ncorporation pursuant to this section shall be payment in full for the\nservices provided. The school-based mental health clinic reimbursed\npursuant to this section shall not charge or seek any reimbursement\nfrom, or have any recourse against, a corporation for the services\nprovided pursuant to this paragraph, except for the collection of\nin-network copayments, coinsurance, or deductibles for which the insured\nis responsible for under the terms of the contract.\n (12) (A) This subparagraph shall apply to outpatient treatment\nprovided 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, that is\nparticipating in the corporation's provider network. Reimbursement for\ncovered outpatient treatment provided by such facility shall be at rates\nnegotiated between the corporation 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 subparagraph, 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 shall be the rates with an\neffective date of April first of the preceding year, which shall be\nestablished prior to October first of the preceding calendar year.\n (B) 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 subparagraph shall be construed to relieve an insurer of the\nobligation to reimburse at no less than the applicable minimum rate set\nforth in subparagraph (A) of this paragraph

e 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 subparagraph shall be construed to relieve an insurer of the\nobligation to reimburse at no less than the applicable minimum rate set\nforth in subparagraph (A) of this paragraph. Prior to the submission of\npremium rate filings and applications, the superintendent shall provide\ncorporations with guidance on factors to consider in calculating the\nimpact of rate changes for the purposes of submitting premium rate\nfilings and applications to the superintendent for the subsequent policy\nyear. To the extent that the rates with an effective date of April first\ndiffer from the estimated rates incorporated in premium rate filings and\napplications, corporations may account for such differences in future\npremium rate filings and applications submitted to the superintendent\nfor approval.\n (j)(1) A health service corporation or medical expense indemnity\ncorporation that provides medical, major-medical or similar\ncomprehensive-type coverage shall provide coverage for the provision of\npreventive and primary care services.\n (2) For purposes of this paragraph and paragraph one of this\nsubsection, preventive and primary care services shall mean the\nfollowing services rendered to a covered child of a subscriber from the\ndate of birth through the attainment of nineteen years of age:\n (A) 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. Coverage shall be provided for such services\nrendered in a hospital, as defined in section twenty-eight hundred one\nof the public health law, or in an office of a physician or other\nprofessional licensed under article one hundred thirty-nine of the\neducation law whose scope of practice pursuant to such law includes the\nauthority to provide the specified services,\n (B) at each visit, services in accordance with the prevailing clinical\nstandards of such designated association, including a medical history, a\ncomplete physical examination, developmental assessment, anticipatory\nguidance, appropriate immunizations and laboratory tests which tests are\nordered at the time of the visit and performed in the practitioner's\noffice, as authorized by law, or in a clinical laboratory, and\n (C) necessary immunizations, as determined by the superintendent in\nconsultation with the commissioner of health, consisting of at least\nadequate dosages of vaccine against diphtheria, pertussis, tetanus,\npolio, measles, rubella, mumps, haemophilus influenzae type b and\nhepatitis b, which meet the standards approved by the United States\npublic health service for such biological products.\n (D) Such coverage required pursuant to this paragraph and paragraph\none of this subsection shall not be subject to annual deductibles or\ncoinsurance.\n (E) Such coverage required pursuant to this paragraph and paragraph\none of this subsection shall not restrict or eliminate existing coverage\nprovided by the contract.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides hospital, surgical or medical care coverage,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall

.\n (E) Such coverage required pursuant to this paragraph and paragraph\none of this subsection shall not restrict or eliminate existing coverage\nprovided by the contract.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides hospital, surgical or medical care coverage,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following preventive care and\nscreenings for subscribers, and such coverage shall not be subject to\nannual deductibles or coinsurance:\n (A) evidence-based items or services for preventive care and\nscreenings that have in effect a rating of 'A' or 'B' in the current\nrecommendations of the United States preventive services task force;\n (B) immunizations that have in effect a recommendation from the\nadvisory committee on immunization practices of the centers for disease\ncontrol and prevention with respect to the individual involved, or that\nare recommended by the commissioner of health to the superintendent\nutilizing generally accepted medical standards and taking into\nconsideration recommendations of the American Academy of Pediatrics, the\nAmerican Academy of Family Physicians, the American College of\nObstetricians and Gynecologists, and the American College of Physicians\nand/or other similar nationally or internationally recognized scientific\norganizations;\n (C) with respect to children, including infants and adolescents,\nevidence-informed preventive care and screenings provided for in\ncomprehensive guidelines supported by the health resources and services\nadministration; and\n (D) with respect to women, such additional preventive care and\nscreenings not described in subparagraph (A) of this paragraph and as\nprovided for in comprehensive guidelines supported by the health\nresources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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 * (k)(1) Every contract 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\ncontract.\n (2) Coverage provided under this subsection 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\nprograms and are similarly licensed, certified or otherwise authorized\nin the state in which the facility is located.\n (3) Coverage provided under this subsection 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 contract.\n (4) This paragraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of alcoholism\nand substance abuse services that are participating in the corporation's\nprovider network

al\ndeductibles and co-insurance as deemed appropriate by the superintendent\nand that are consistent with those imposed on other benefits within a\ngiven contract.\n (4) This paragraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of alcoholism\nand substance abuse services that are participating in the corporation's\nprovider network. Coverage provided under this subsection shall not be\nsubject to preauthorization. Coverage provided under this subsection\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 corporation 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 corporation at or just prior to the fourteenth day\nof treatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the corporation which is\ndesignated by the office of alcoholism and substance abuse services 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 corporation 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 corporation which is designated by the office of\nalcoholism and substance abuse services. Prior to discharge, the\nfacility shall indicate to the corporation whether services included in\nthe discharge plan are secured or determined to be reasonably available.\nAny utilization review of treatment provided under this paragraph 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 corporation\nshall only 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 corporation which\nis designated by the office of alcoholism and substance abuse services.\nAn insured shall not have any financial obligation to the facility for\nany treatment under this paragraph other than any copayment,\ncoinsurance, or deductible otherwise required under the contract.\n (5) The criteria for medical necessity determinations under the\ncontract with respect to inpatient substance use disorder benefits shall\nbe made available by the corporation to any insured, prospective insured\nor in-network provider upon request.\n (6) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (C) "treatment limitation" means limits on the frequency of treatment,\nnumber of visits, days of coverage, or other similar limits on the scope\nor duration of treatment and includes nonquantitative treatment\nlimitations such as: medical management standards limiting or excluding\nbenefits based on medical necessity, or based on whether the treatment\nis experimental or investigational; formulary design for prescription\ndrugs; network tier design; standards for provider admission to\nparticipate in a network, including reimbursement rates; methods for\ndetermining usual, customary, and reasonable charges; fail-first or step\ntherapy protocols; exclusions based on failure to complete a course of\ntreatment; and

based on whether the treatment\nis experimental or investigational; formulary design for prescription\ndrugs; network tier design; standards for provider admission to\nparticipate in a network, including reimbursement rates; methods for\ndetermining usual, customary, and reasonable charges; fail-first or step\ntherapy protocols; exclusions based on failure to complete a course of\ntreatment; and restrictions based on geographic location, facility type,\nprovider specialty, and other criteria that limit the scope or duration\nof benefits for services provided under the contract; and\n (D) "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 (7) A corporation shall provide coverage under this subsection, 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 * NB Effective until January 1, 2027\n * (k)(1) Every contract that provides hospital, major medical or\nsimilar comprehensive 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 contract.\n (2) Coverage provided under this subsection 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 (3) Coverage provided under this subsection 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 contract.\n (4) This paragraph shall apply to facilities in this state that are\nlicensed, certified or otherwise authorized by the office of addiction\nservices and supports that are participating in the corporation's\nprovider network. Coverage provided under this subsection shall not be\nsubject to preauthorization. Coverage provided under this subsection\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 corporation 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 corporation at or just prior to the fourteenth day\nof treatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the corporation 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

sultation with the corporation at or just prior to the fourteenth day\nof treatment to ensure that the facility is using the evidence-based and\npeer reviewed clinical review tool utilized by the corporation 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 corporation 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 corporation which is designated by the office of\naddiction services and supports. Prior to discharge, the facility shall\nindicate to the corporation whether services included in the discharge\nplan are secured or determined to be reasonably available. Any\nutilization review of treatment provided under this paragraph 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 corporation\nshall only 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 corporation which\nis designated by the office of addiction services and supports. An\ninsured shall not have any financial obligation to the facility for any\ntreatment under this paragraph other than any copayment, coinsurance, or\ndeductible otherwise required under the contract.\n (5) The criteria for medical necessity determinations under the\ncontract with respect to inpatient substance-related and addictive\ndisorder benefits shall be made available by the corporation to any\ninsured, prospective insured or in-network provider upon request.\n (6) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement;\n (C) "treatment limitation" means limits on the frequency of treatment,\nnumber of visits, days of coverage, or other similar limits on the scope\nor duration of treatment and includes nonquantitative treatment\nlimitations such as: medical management standards limiting or excluding\nbenefits based on medical necessity, or based on whether the treatment\nis experimental or investigational; formulary design for prescription\ndrugs; network tier design; standards for provider admission to\nparticipate in a network, including reimbursement rates; methods for\ndetermining usual, customary, and reasonable charges; fail-first or step\ntherapy protocols; exclusions based on failure to complete a course of\ntreatment; and restrictions based on geographic location, facility type,\nprovider specialty, and other criteria that limit the scope or duration\nof benefits for services provided under the contract; and\n (D) "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 (7) A corporation shall provide coverage under this subsection, 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

\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 (7) A corporation shall provide coverage under this subsection, 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 * NB Effective January 1, 2027\n * (l) (1) Every contract that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide outpatient coverage\nfor the diagnosis 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 contract.\n (2) Coverage under this subsection may be limited to facilities in\nthis state that are licensed, certified or otherwise authorized by the\noffice of addiction services and supports to provide outpatient\nsubstance use disorder services and crisis stabilization centers\nlicensed pursuant to section 36.01 of the mental hygiene law, and, in\nother states, to those which are accredited by the joint commission as\nalcoholism or chemical dependence substance abuse treatment programs and\nare similarly licensed, certified or otherwise authorized in the state\nin which the facility is located.\n (3) Coverage provided under this subsection 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 contract.\n (3-a) A contract that provides large group coverage under this\nsubsection shall not impose copayments or coinsurance for outpatient\nsubstance use disorder services that exceed the copayment or coinsurance\nimposed for a primary care office visit. Provided that no greater than\none such copayment may be imposed for all services provided in a single\nday by a facility licensed, certified or otherwise authorized by the\noffice of alcoholism and substance abuse services to provide outpatient\nsubstance use disorder services.\n (4) A contract providing coverage for substance use disorder services\npursuant to this subsection shall provide up to twenty outpatient visits\nper contract 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 contract pursuant to this subsection. The\ncoverage required by this subsection shall include treatment as a family\nmember pursuant to such family member's own contract provided such\nfamily member:\n (A) does not exceed the allowable number of family visits provided by\nthe applicable contract pursuant to this subsection; and\n (B) is otherwise entitled to coverage pursuant to this subsection and\nsuch family member's applicable contract.\n (5) This paragraph 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 corporation's provider network. Coverage provided\nunder this subsection shall not be subject to preauthorization. Coverage\nprovided under this subsection 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 corporation of\nboth the start of treatment and the initial treatment plan within two\nbusiness days

er network. Coverage provided\nunder this subsection shall not be subject to preauthorization. Coverage\nprovided under this subsection 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 corporation of\nboth the 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\ncorporation at or just prior to the fourteenth day of treatment to\nensure that the facility is using the evidence-based and peer reviewed\nclinical review tool utilized by the corporation which is designated by\nthe office of alcoholism and substance abuse services and appropriate to\nthe age of the patient, to ensure that the outpatient treatment is\nmedically necessary for the patient. Any utilization review of the\ntreatment provided under this paragraph may include a review of all\nservices provided during such outpatient treatment, including all\nservices provided during the first four weeks of continuous treatment,\nnot to exceed twenty-eight visits, of such outpatient treatment.\nProvided, however, the corporation shall only deny coverage for any\nportion of the initial four weeks of continuous treatment, not to exceed\ntwenty-eight visits, for outpatient treatment on the basis that such\ntreatment was not medically necessary if such outpatient treatment was\ncontrary to the evidence-based and peer reviewed clinical review tool\nutilized by the corporation which is designated by the office of\nalcoholism and substance abuse services. A subscriber shall not have any\nfinancial obligation to the facility for any treatment under this\nparagraph other than any copayment, coinsurance, or deductible otherwise\nrequired under the contract.\n (6) The criteria for medical necessity determinations under the\ncontract with respect to outpatient substance use disorder benefits\nshall be made available by the corporation to any insured, prospective\ninsured, or in-network provider upon request.\n (7) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement.\n (C) "treatment limitation" means limits on the frequency of treatment,\nnumber of visits, days of coverage, or other similar limits on the scope\nor duration of treatment and includes nonquantitative treatment\nlimitations such as: medical management standards limiting or excluding\nbenefits based on medical necessity, or based on whether the treatment\nis experimental or investigational; formulary design for prescription\ndrugs; network tier design; standards for provider admission to\nparticipate in a network, including reimbursement rates; methods for\ndetermining usual, customary, and reasonable charges; fail-first or step\ntherapy protocols; exclusions based on failure to complete a course of\ntreatment; and restrictions based on geographic location, facility type,\nprovider specialty, and other criteria that limit the scope or duration\nof benefits for services provided under the contract; and\n (D) "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 (8) A corporation shall provide coverage under this subsection, 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

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 (8) A corporation shall provide coverage under this subsection, 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 (9) This paragraph shall apply to crisis stabilization centers in this\nstate that are licensed pursuant to section 36.01 of the mental hygiene\nlaw and participate in the corporation's provider network. Benefits for\ncare in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or\ndeductible otherwise required under the contract.\n (10) (A) This subparagraph shall apply to facilities in this state\nthat are licensed, certified, or otherwise authorized by the office of\naddiction services and supports for the provision of outpatient,\nintensive outpatient, outpatient rehabilitation and opioid treatment\nthat are participating in the corporation's provider network.\nReimbursement for covered outpatient treatment provided by such\nfacilities shall be at rates negotiated between the corporation and the\nparticipating facility, provided that such rates are not less than the\nrates that would be paid for such treatment pursuant to the medical\nassistance program under title eleven of article five of the social\nservices law. For the purposes of this subparagraph, 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 (B) 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 subparagraph shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in subparagraph (A) of\nthis paragraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide corporations 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, corporations may account for such differences in future\npremium rate filings and applications submitted to the superintendent\nfor approval.\n * NB Effective until January 1, 2027\n * (l) (1) Every contract that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide outpatient coverage\nfor the diagnosis and treatment of substance-related and addictive\ndisorder, including detoxification and rehabilitation services

ure\npremium rate filings and applications submitted to the superintendent\nfor approval.\n * NB Effective until January 1, 2027\n * (l) (1) Every contract that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide outpatient coverage\nfor the diagnosis and treatment of substance-related and addictive\ndisorder, including detoxification and rehabilitation services. Such\ncoverage shall not apply financial requirements or treatment limitations\nto outpatient 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 contract.\n (2) Coverage under this subsection may be limited to facilities in\nthis state that are licensed, certified or otherwise authorized by the\noffice of 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\nsubstance abuse treatment programs and are similarly licensed, certified\nor otherwise authorized in the state in which the facility is located.\n (3) Coverage provided under this subsection 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 contract.\n (3-a) A contract that provides large group coverage under this\nsubsection shall not impose copayments or coinsurance for outpatient\nsubstance-related and addictive disorder services that exceed 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 (4) A contract providing coverage for substance-related and addictive\ndisorder services pursuant to this subsection shall provide up to twenty\noutpatient visits per contract or calendar year to an individual who\nidentifies themselves as a family member of a person suffering from\nsubstance-related and addictive disorder and who seeks treatment as a\nfamily member who is otherwise covered by the applicable contract\npursuant to this subsection. The coverage required by this subsection\nshall include treatment as a family member pursuant to such family\nmember's own contract provided such family member:\n (A) does not exceed the allowable number of family visits provided by\nthe applicable contract pursuant to this subsection; and\n (B) is otherwise entitled to coverage pursuant to this subsection and\nsuch family member's applicable contract.\n (5) This paragraph 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 corporation's provider network. Coverage provided\nunder this subsection shall not be subject to preauthorization. Coverage\nprovided under this subsection 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 corporation of\nboth the start of treatment and the initial treatment plan within two\nbusiness days

er network. Coverage provided\nunder this subsection shall not be subject to preauthorization. Coverage\nprovided under this subsection 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 corporation of\nboth the 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\ncorporation at or just prior to the fourteenth day of treatment to\nensure that the facility is using the evidence-based and peer reviewed\nclinical review tool utilized by the corporation which is designated by\nthe office of addiction services and supports and appropriate to the age\nof the patient, to ensure that the outpatient treatment is medically\nnecessary for the patient. Any utilization review of the treatment\nprovided under this paragraph 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 corporation 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\ncorporation which is designated by the office of addiction services and\nsupports. A subscriber shall not have any financial obligation to the\nfacility for any treatment under this paragraph other than any\ncopayment, coinsurance, or deductible otherwise required under the\ncontract.\n (6) The criteria for medical necessity determinations under the\ncontract with respect to outpatient substance-related and addictive\ndisorder benefits shall be made available by the corporation to any\ninsured, prospective insured, or in-network provider upon request.\n (7) For purposes of this subsection:\n (A) "financial requirement" means deductible, copayments, coinsurance\nand out-of-pocket expenses;\n (B) "predominant" means that a financial requirement or treatment\nlimitation is the most common or frequent of such type of limit or\nrequirement.\n (C) "treatment limitation" means limits on the frequency of treatment,\nnumber of visits, days of coverage, or other similar limits on the scope\nor duration of treatment and includes nonquantitative treatment\nlimitations such as: medical management standards limiting or excluding\nbenefits based on medical necessity, or based on whether the treatment\nis experimental or investigational; formulary design for prescription\ndrugs; network tier design; standards for provider admission to\nparticipate in a network, including reimbursement rates; methods for\ndetermining usual, customary, and reasonable charges; fail-first or step\ntherapy protocols; exclusions based on failure to complete a course of\ntreatment; and restrictions based on geographic location, facility type,\nprovider specialty, and other criteria that limit the scope or duration\nof benefits for services provided under the contract; and\n (D) "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 (8) A corporation shall provide coverage under this subsection, 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

\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 (8) A corporation shall provide coverage under this subsection, 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 (9) This paragraph shall apply to crisis stabilization centers in this\nstate that are licensed pursuant to section 36.01 of the mental hygiene\nlaw and participate in the corporation's provider network. Benefits for\ncare in a crisis stabilization center shall not be subject to\npreauthorization. All treatment provided under this paragraph 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 paragraph other than any copayment, coinsurance, or\ndeductible otherwise required under the contract.\n (10) (A) This subparagraph shall apply to facilities in this state\nthat are licensed, certified, or otherwise authorized by the office of\naddiction services and supports for the provision of outpatient,\nintensive outpatient, outpatient rehabilitation and opioid treatment\nthat are participating in the corporation's provider network.\nReimbursement for covered outpatient treatment provided by such\nfacilities shall be at rates negotiated between the corporation and the\nparticipating facility, provided that such rates are not less than the\nrates that would be paid for such treatment pursuant to the medical\nassistance program under title eleven of article five of the social\nservices law. For the purposes of this subparagraph, 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 (B) 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 subparagraph shall be\nconstrued to relieve an insurer of the obligation to reimburse at no\nless than the applicable minimum rate set forth in subparagraph (A) of\nthis paragraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide corporations 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

than the applicable minimum rate set forth in subparagraph (A) of\nthis paragraph. Prior to the submission of premium rate filings and\napplications, the superintendent shall provide corporations 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, corporations may account for such differences in future\npremium rate filings and applications submitted to the superintendent\nfor approval.\n * NB Effective January 1, 2027\n (l-1) * (A) No contract that provides medical, major medical or\nsimilar comprehensive-type individual or small group coverage and\nprovides coverage for prescription drugs for medication for the\ntreatment of a substance use disorder shall require prior authorization\nfor an initial or renewal prescription for the detoxification or\nmaintenance treatment of a substance use disorder, including all\nbuprenorphine products, methadone, long acting injectable naltrexone, or\nmedication for opioid overdose reversal prescribed or dispensed to an\ninsured covered under the contract, including federal food and drug\nadministration-approved over-the-counter opioid overdose reversal\nmedication as prescribed, dispensed or as otherwise authorized under\nstate or federal law, except where otherwise prohibited by law. Every\ncontract that provides medical, major medical, or similar\ncomprehensive-type large group coverage shall provide coverage for\nprescription drugs for medication for the treatment of a substance use\ndisorder and shall not require prior authorization for an initial or\nrenewal prescription for the detoxification of 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 individual covered under\nthe contract, 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 contract that provides medical, major medical or similar\ncomprehensive-type individual or small group coverage and provides\ncoverage for prescription 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\ncontract, 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

products, methadone,\nlong acting injectable naltrexone, or medication for opioid overdose\nreversal prescribed or dispensed to an insured covered under the\ncontract, 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. Every contract that provides medical,\nmajor medical, or similar comprehensive-type large group coverage shall\nprovide coverage for prescription drugs for medication for the treatment\nof a substance-related and addictive disorder and shall not require\nprior authorization for an initial or renewal prescription for the\ndetoxification of 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 individual covered under the\ncontract, 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 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 (l-2) 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 (m) A medical expense indemnity corporation or a health service\ncorporation which provides coverage for any service within the lawful\nscope of practice of a duly licensed registered professional nurse must\nmake available, and if requested by all subscribers in a group\nremittance group, or by a contract holder in the case of a group\ncontract issued pursuant to section four thousand three hundred five of\nthis chapter, provide reimbursement for such services when performed by\na duly licensed registered professional nurse provided, however, that\nreimbursement shall not be made for nursing services provided to a\nsubscriber in a general hospital, nursing home, or a facility providing\nhealth related services, as such terms are defined in section\ntwenty-eight hundred one of the public health law, or in a facility, as\nsuch term is defined in subdivision six of section 1.03 of the mental\nhygiene law, or in a physician's office. Such coverage may be subject to\nannual deductibles and co-insurance as may be deemed appropriate by the\nsuperintendent and are consistent with those imposed on other benefits\nwithin a given policy. Such coverage shall not replace, restrict or\neliminate existing coverage provided by the policy. Coverage for the\nservices of a duly licensed registered professional nurse need be\nprovided only if the nature of the patient's illness or condition\nrequires nursing care which can appropriately be provided by a person\nwith the education and professional skill of a registered professional\nnurse and the nursing care is necessary in the treatment of the\npatient's illness or condition

e policy. Coverage for the\nservices of a duly licensed registered professional nurse need be\nprovided only if the nature of the patient's illness or condition\nrequires nursing care which can appropriately be provided by a person\nwith the education and professional skill of a registered professional\nnurse and the nursing care is necessary in the treatment of the\npatient's illness or condition. Written notice of the availability of\nsuch coverage shall be delivered to the group remitting agent or group\ncontract holder prior to inception of such contract 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 (n) Every health service or medical expense indemnity corporation\nissuing a group contract pursuant to this section or a group remittance\ncontract for delivery in this state which contract provides\nreimbursement to subscribers or physicians, psychiatrists or\npsychologists for psychiatric or psychological services or for the\ndiagnosis and treatment of mental health conditions, however defined in\nsuch contract, must provide the same coverage to persons covered under\nthe group contract 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 a mental health counselor, marriage and family\ntherapist, or psychoanalyst licensed pursuant to article one hundred\nsixty-three of the education law. Nothing herein shall be construed to\nmodify or expand the scope of practice of a mental health counselor,\nmarriage and family therapist, or psychoanalyst licensed pursuant to\narticle one hundred sixty-three of the education law. Further, nothing\nherein shall be construed to create a new mandated health benefit. The\nstate board for social work shall maintain a list of all licensed\nclinical social workers qualified for reimbursement under this\nsubsection. The state board for mental health practitioners shall\nmaintain a list of all licensed mental health counselors, marriage and\nfamily therapists, or psychoanalysts qualified for reimbursement under\nthis subsection.\n (o) A hospital service corporation or a health service corporation\nwhich provides coverage for inpatient hospital care must make available\nand, if requested by all persons holding individual contracts in a group\nwhose premiums are paid by a remitting agent or by the contractholder in\nthe case of a group contract issued pursuant to section four thousand\nthree hundred five of this article, provide coverage for hospice care.\nFor the purposes of this subsection, hospice care shall mean the care\nand treatment of a covered person who has been certified by such\nperson's primary attending physician as having a life expectancy of six\nmonths or less and which is provided by a hospice organization certified\npursuant to article forty of the public health law or under a similar\ncertification process required by the state in which the hospice\norganization is located

care shall mean the care\nand treatment of a covered person who has been certified by such\nperson's primary attending physician as having a life expectancy of six\nmonths or less and which is provided by a hospice organization certified\npursuant to article forty of the public health law or under a similar\ncertification process required by the state in which the hospice\norganization is located. Hospice care coverage shall be at least equal\nto: (1) a total of two hundred ten days of coverage beginning with the\nfirst day on which care is provided, for inpatient hospice care in a\nhospice or in a hospital and home care and outpatient services provided\nby the hospice, including drugs and medical supplies, and (2) five\nvisits for bereavement counseling services, either before or after the\ninsured's death, provided to the family of the terminally ill insured.\nSuch coverage shall be made available at the inception of all new\ncontracts and, with respect to contracts issued before the effective\ndate of this provision, at the first annual anniversary date thereafter,\nwithout evidence of insurability and at any subsequent annual\nanniversary date subject to evidence of insurability. Such coverage may\nbe subject to annual deductibles and coinsurance as may be deemed\nappropriate by the superintendent and are consistent with those imposed\non other benefits within a given contract period. Written notice of the\navailability of such coverage shall be delivered to the group remitting\nagent or group contract holder prior to inception of such contract and\nannually thereafter, except that this notice shall not be required where\na policy covers two hundred or more employees or where the benefit\nstructure was the subject of collective bargaining affecting persons who\nare employed in more than one state.\n (p) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation that provides coverage for\nhospital, surgical or medical care shall provide the following coverage\nfor mammography screening for occult breast cancer:\n (A) upon the recommendation of a physician, a mammogram, which may be\nprovided by breast tomosynthesis, at any age for covered persons having\na prior history of breast cancer or who have a first degree relative\nwith a prior history of breast cancer;\n (B) a single baseline mammogram, which may be provided by breast\ntomosynthesis, for covered persons aged thirty-five through thirty-nine,\ninclusive;\n (C) an annual mammogram, which may be provided by breast tomosythesis,\nfor covered persons aged forty and older;\n (D) for large group contracts offered by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation that provide coverage for hospital, surgical or medical\ncare, an annual mammogram for covered persons aged thirty-five through\nthirty-nine, inclusive, upon the recommendation of a physician, subject\nto the corporation's determination that the mammogram is medically\nnecessary;\n (E) upon the recommendation of a physician, screening and diagnostic\nimaging, including diagnostic mammograms, breast ultrasounds, or\nmagnetic resonance imaging, recommended by nationally recognized\nclinical practice guidelines for the detection of breast cancer. For the\npurposes of this subparagraph, "nationally recognized clinical practice\nguidelines" means evidence-based clinical practice guidelines informed\nby a systematic review of evidence and an assessment of the benefits,\nand risks of alternative care options intended to optimize patient care\ndeveloped by independent organizations or medical professional societies\nutilizing a transparent methodology and reporting structure and with a\nconflict of interest policy; and\n * (F) The coverage required in this paragraph or paragraph two of this\nsubsection shall not be subject to annual deductibles or coinsurance

ts,\nand risks of alternative care options intended to optimize patient care\ndeveloped by independent organizations or medical professional societies\nutilizing a transparent methodology and reporting structure and with a\nconflict of interest policy; and\n * (F) The coverage required in this paragraph or paragraph two of this\nsubsection shall not be subject to annual deductibles or coinsurance. If\nunder federal law, application of this requirement would result in\nhealth savings account ineligibility under 26 USC 223, this requirement\nshall apply for health savings account-qualified high deductible health\nplans with respect to the deductible of such a plan after the enrollee\nhas satisfied the minimum deductible under 26 USC 223, 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 * NB Effective until January 1, 2027\n * (F) The coverage required in this paragraph or paragraph two of this\nsubsection shall not be subject to annual deductibles or coinsurance. If\nunder federal law, application of this requirement would result in\nhealth savings account ineligibility under 26 USC 223, this requirement\nshall apply for health savings account-qualified high deductible health\nplans with respect to the deductible of such a plan after the enrollee\nhas satisfied the plan deductible, except for with respect to items or\nservices that are preventive care pursuant to 26 USC 223(c)(2)(C), in\nwhich case the requirements of this paragraph shall apply regardless of\nwhether the plan deductible has been satisfied.\n * NB Effective January 1, 2027\n (2) For purposes of paragraph one of this subsection, mammography\nscreening means an X-ray examination of the breast using dedicated\nequipment, including X-ray tube, filter, compression device, screens,\nfilms and cassettes, with an average glandular radiation dose less than\n0.5 rem per view per breast; provided, however, that mammography\nscreening shall also include breast tomosythesis.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides coverage for hospital, surgical or medical care,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following mammography\nscreening services, and such coverage shall not be subject to annual\ndeductibles or coinsurance:\n (A) evidence-based items or services for mammography that have in\neffect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n (B) with respect to women, such additional preventive care and\nscreenings for mammography not described in subparagraph (A) of this\nparagraph and as provided for in comprehensive guidelines supported by\nthe health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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

nsive guidelines supported by\nthe health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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 (p-1) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation that provides coverage for\nmedical, major medical, or similar comprehensive-type coverage shall\nprovide coverage for biomarker precision medical testing for the\npurposes of diagnosis, treatment, or appropriate management of, or\nongoing monitoring to guide treatment decisions for, an insured's\ndisease or condition when one or more of the following recognizes the\nefficacy and appropriateness of biomarker precision medical testing for\ndiagnosis, treatment, appropriate management, or guiding treatment\ndecisions for an insured's disease or condition:\n (A) labeled indications for a test approved or cleared by the federal\nfood and drug administration or indicated tests for a food and drug\nadministration approved drug;\n (B) centers for medicare and medicaid services national coverage\ndeterminations or medicare administrative contractor local coverage\ndeterminations;\n (C) nationally recognized clinical practice guidelines; or\n (D) peer-reviewed literature and peer-reviewed scientific studies\npublished in or accepted for publication by medical journals that meet\nnationally recognized requirements for scientific manuscripts and that\nsubmit most of their published articles for review by experts who are\nnot part of the editorial staff.\n (2) Such coverage shall be provided in a manner that shall limit\ndisruptions in care including the need for multiple biopsies or\nbiospecimen samples.\n (3) As used in this subsection, the following terms shall have the\nfollowing meanings:\n (A) "Biomarker" means a characteristic that is measured as an\nindicator of normal biological processes, pathogenic processes, or\nresponses to an exposure or intervention, including therapeutic\ninterventions.\n (B) "Biomarker precision medical testing" means the analysis of a\npatient's tissue, blood, or other biospecimen for the presence of a\nbiomarker. Biomarker testing includes but is not limited to\nsingle-analyte tests and multi-plex panel tests performed at a\nparticipating in-network laboratory facility that is either CLIA\ncertified or CLIA waived by the federal food and drug administration.\n (C) "Nationally recognized clinical practice guidelines" means\nevidence-based clinical practice guidelines informed by a systematic\nreview of evidence and an assessment of the benefits, and risks of\nalternative care options intended to optimize patient care developed by\nindependent organizations or medical professional societies utilizing a\ntransparent methodology and reporting structure and with a conflict of\ninterest policy.\n (q) (1) Every policy issued by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation which provides coverage for prescribed drugs approved by the\nfood and drug administration of the United States government for the\ntreatment of certain types of cancer shall not exclude coverage of any\nsuch drug on the basis that such drug has been prescribed for the\ntreatment of a type of cancer for which the drug has not been approved\nby the food and drug administration

service\ncorporation which provides coverage for prescribed drugs approved by the\nfood and drug administration of the United States government for the\ntreatment of certain types of cancer shall not exclude coverage of any\nsuch drug on the basis that such drug has been prescribed for the\ntreatment of a type of cancer for which the drug has not been approved\nby the food and drug administration. Provided, however, that such drug\nmust be recognized for treatment of the specific type of cancer for\nwhich the drug has been prescribed in one of the following established\nreference compendia:\n (i) the American Hospital Formulary Service-Drug Information\n(AHFS-DI);\n (ii) National Comprehensive Cancer Networks Drugs and Biologics\nCompendium;\n (iii) Thomson Micromedex DrugDex;\n (iv) Elsevier Gold Standard's Clinical Pharmacology; or other\nauthoritative compendia as identified by the Federal Secretary of Health\nand Human Services or the Centers for Medicare & Medicaid Services\n(CMS); or recommended by review article or editorial comment in a major\npeer reviewed professional journal.\n (2) Notwithstanding the provisions of this subsection, coverage shall\nnot be required for any experimental or investigational drugs or any\ndrug which the food and drug administration has determined to be\ncontraindicated for treatment of the specific type of cancer for which\nthe drug has been prescribed. The provisions of this subsection shall\napply to cancer drugs only and nothing herein shall be construed to\ncreate, impair, alter, limit, modify, enlarge, abrogate or prohibit\nreimbursement for drugs used in the treatment of any other disease or\ncondition.\n (q-1) (1) Every contract issued by a medical expense indemnity\ncorporation, a hospital service corporation or a health service\ncorporation for delivery in this state that provides medical, major\nmedical or similar comprehensive-type coverage and provides coverage for\nprescription drugs and for cancer chemotherapy treatment shall provide\ncoverage for prescribed, orally administered anticancer medications used\nto kill or slow the growth of cancerous cells. Such coverage may be\nsubject to co-pays, coinsurance or deductibles, provided that the\nco-pays, coinsurance or deductibles are at least as favorable to an\ninsured as the co-pays, coinsurance or deductibles that apply to\ncoverage for intravenous or injected anticancer medications.\n (2) An insurer providing coverage under this paragraph and any\nparticipating entity through which the insurer offers health services\nshall not:\n (A) vary the terms of the contract for the purpose or with the effect\nof avoiding compliance with this paragraph;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nparagraph;\n (C) 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 (D) 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 (E) achieve compliance with this paragraph by imposing an increase in\ncost sharing for an intravenous or injected anticancer medication.\n (q-2) (1) Every large group contract delivered or issued for delivery\nin this state that provides medical, major medical, or similar\ncomprehensive-type coverage and provides coverage for cancer\nchemotherapy treatment shall provide coverage for scalp cooling systems\nused in connection with cancer chemotherapy treatment

se in\ncost sharing for an intravenous or injected anticancer medication.\n (q-2) (1) Every large group contract delivered or issued for delivery\nin this state that provides medical, major medical, or similar\ncomprehensive-type coverage and provides coverage for cancer\nchemotherapy treatment shall provide coverage for scalp cooling systems\nused in connection with cancer chemotherapy treatment. Coverage provided\nunder this subsection may be subject to annual deductibles and\ncoinsurance, including copayments, as may be deemed appropriate by the\nsuperintendent and as are consistent with those established for other\nbenefits within a given contract.\n (2) For the purposes of this subsection, "scalp cooling system" means\nany device used to cool the human scalp to prevent or reduce hair loss\nduring cancer chemotherapy treatment, provided that such device is\ndesigned and intended for repeated use and is primarily and customarily\nused to serve a medical purpose.\n (r) Consistent with federal law, a hospital service corporation or a\nhealth service corporation which provides coverage supplementing part A\nand part B of subchapter XVIII of the federal Social Security Act, 42\nUSC §§ 1395 et seq., shall make available and, if requested by a person\nholding a direct payment individual contract or by all persons holding\nindividual contracts in a group whose premiums are paid by a remitting\nagent or by a contract holder in the case of a group contract issued\npursuant to section four thousand three hundred five of this article,\nprovide coverage for at least ninety days of care in a nursing home as\ndefined in section twenty-eight hundred one of the public health law,\nexcept when such coverage would duplicate coverage that is available\nunder the aforementioned subchapter XVIII. Such coverage shall be made\navailable at the inception of all new contracts and, with respect to all\nother contracts at each anniversary date of the contract.\n (1) Coverage shall be subject to a copayment of twenty-five dollars\nper day.\n (2) Brochures describing such coverage must be provided at the time of\napplication for all new contracts and thereafter on each anniversary\ndate of the contract, and with respect to all other contracts annually\nat each anniversary date of the contract. Such brochures must be\napproved by the superintendent in consultation with the commissioner of\nhealth.\n Such insurers shall report to the superintendent each year the number\nof contract holders to whom such insurers have issued such policies for\nnursing home coverage and the approximate number of persons covered by\nsuch policies.\n (3) The commensurate rate for the coverage must be approved by the\nsuperintendent.\n * (s) (1) A hospital service corporation or health service corporation\nwhich provides 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 (A) subject to the provisions of paragraph three of this subsection,\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 (B) provided, further however, that subject to the provisions of\nparagraph three of this subsection, 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 subsection,\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 (C) provided,

ine infertility or that are\nnecessary in connection with any surgical or medical treatments or\nprescription drug coverage provided pursuant to this subsection,\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 (C) 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 paragraph three of this subsection.\n (2) A medical expense indemnity or health service corporation 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 (A) subject to the provisions of paragraph three of this subsection,\nin no case shall such coverage exclude surgical or medical procedures\nwhich would correct malformation, disease or dysfunction resulting in\ninfertility; and\n (B) provided, further however, that subject to the provisions of\nparagraph three of this subsection, 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 subsection, 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 (C) 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 paragraph three of this subsection.\n (3) Coverage of diagnostic and treatment procedures, including\nprescription drugs used in the diagnosis and treatment of infertility as\nrequired by paragraphs one and two of this subsection shall be provided\nin accordance with this paragraph.\n (A) 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 paragraph.\n (B) 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 (C) Except as provided in subparagraphs (F) and (G) of this paragraph,\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 subparagraph (D) of this paragraph.\n (D) 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 paragraph, 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

dards which shall be used in carrying out the\nprovisions of this paragraph, 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 (E)(i) For the purposes of this subsection, "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 subsection, "iatrogenic infertility" means\nan impairment of fertility by surgery, radiation, chemotherapy or other\nmedical treatment affecting reproductive organs or processes.\n (F) 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 contract.\n (G) Every large group contract that provides medical, major medical or\nsimilar comprehensive-type coverage shall provide coverage for three\ncycles of in-vitro fertilization used in the treatment of infertility.\nCoverage may 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\ncontract. For purposes of this subparagraph, a "cycle" is defined as\neither all treatment that starts when: preparatory medications are\nadministered for ovarian stimulation for oocyte retrieval with the\nintent of undergoing in-vitro fertilization using a fresh embryo\ntransfer; or medications are administered for endometrial preparation\nwith the intent of undergoing in-vitro fertilization using a frozen\nembryo transfer.\n (H) No corporation providing coverage under this subsection shall\ndiscriminate based on an insured's expected length of life, present or\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 (4) Every contract issued by a medical expense indemnity corporation,\na hospital service corporation or a health services corporation that\nprovides coverage for prescription fertility drugs and requires or\npermits prescription drugs to be purchased through a network\nparticipating mail order or other non-retail pharmacy shall provide the\nsame coverage for prescription fertility drugs when such drugs are\npurchased from a network participating non-mail ord

ation,\na hospital service corporation or a health services corporation that\nprovides coverage for prescription fertility drugs and requires or\npermits prescription drugs to be purchased through a network\nparticipating mail order or other non-retail pharmacy shall provide the\nsame coverage for prescription fertility drugs when such drugs are\npurchased from a network participating non-mail order retail pharmacy\nprovided that the network participating non-mail order retail pharmacy\nagrees in advance, through a contractual network agreement, to the same\nreimbursement amount, as well as the same applicable terms and\nconditions, that the corporation has established for the network\nparticipating mail order or other non-retail pharmacy. In such case, the\ncontract shall not impose any fee, co-payment, co-insurance, deductible\nor other condition on any covered person who does not elect to purchase\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 contract that is the result of a collective\nbargaining agreement between an employer and a recognized or certified\nemployee organization.\n * NB There are 2 sb (s)'s\n * (s) Notwithstanding any provision of a contract issued by a medical\nexpense indemnity corporation, a dental expense indemnity corporation or\nhealth service corporation, every contract which provides coverage for\ncare provided through licensed health professionals who can bill for\nservices shall provide the same coverage and reimbursement for such\nservice provided pursuant to a clinical practice plan established\npursuant to subdivision fourteen of section two hundred six of the\npublic health law.\n * NB There are 2 sb (s)'s\n (t) (1) A medical expense indemnity corporation, a hospital service\ncorporation or a health service corporation that provides coverage for\nhospital, surgical, or medical care shall provide coverage for an annual\ncervical cytology screening for cervical cancer and its precursor states\nfor women aged eighteen and older. Such coverage required by 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 contract.\n (2) For purposes of paragraph one of this subsection, cervical\ncytology screening shall include an annual pelvic examination,\ncollection and preparation of a Pap smear, and laboratory and diagnostic\nservices provided in connection with examining and evaluating the Pap\nsmear.\n (3) In addition to paragraph one or two of this subsection, every\ncontract that provides coverage for hospital, surgical or medical care,\nexcept for a grandfathered health plan under paragraph four of this\nsubsection, shall provide coverage for the following cervical cytology\nscreening services, and such coverage shall not be subject to annual\ndeductibles or coinsurance:\n (A) evidence-based items or services for cervical cytology that have\nin effect a rating of 'A' or 'B' in the current recommendations of the\nUnited States preventive services task force; and\n (B) with respect to women, such additional preventive care and\nscreenings for cervical cytology not described in subparagraph (A) of\nthis paragraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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

nsive guidelines supported\nby the health resources and services administration.\n (4) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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 (u) (1) A medical expense indemnity corporation or a health service\ncorporation which provides medical coverage that includes coverage for\nphysician services in a physician's office and every policy which\nprovides major medical or similar comprehensive-type coverage shall\ninclude coverage for the following equipment and supplies for the\ntreatment of diabetes, if recommended or prescribed by a physician or\nother licensed health care provider legally authorized to prescribe\nunder title eight of the education law: blood glucose monitors and blood\nglucose monitors for the visually impaired, data management systems,\ntest strips for glucose monitors and visual reading and urine testing\nstrips, insulin, injection aids, cartridges for the visually impaired,\nsyringes, insulin pumps and appurtenances thereto, insulin infusion\ndevices, and oral agents for controlling blood sugar. In addition, the\ncommissioner of the department of health shall provide and periodically\nupdate by rule or regulation a list of additional diabetes equipment and\nrelated supplies such as are medically necessary for the treatment of\ndiabetes, for which there shall also be coverage. Such policies shall\nalso include coverage for diabetes self-management education to ensure\nthat persons with diabetes are educated as to the proper self-management\nand treatment of their diabetic condition, including information on\nproper diets. Such coverage for self-management education and education\nrelating to diet shall be limited to visits medically necessary upon the\ndiagnosis of diabetes, where a physician diagnoses a significant change\nin the patient's symptoms or conditions which necessitate changes in a\npatient's self-management, or where reeducation or refresher education\nis necessary. 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 (2) 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 (3) This subsection 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 (u-1) A medical expense indemnity corporation or a health service\ncorporation which provides medical coverage that includes coverage for\nphysician services in a physician's office

s 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 (u-1) A medical expense indemnity corporation or a health service\ncorporation which provides medical coverage that includes coverage for\nphysician services in a physician's office and every policy which\nprovides major medical or similar comprehensive-type coverage shall\ninclude coverage for equipment and supplies used for the treatment of\nostomies, if prescribed by a physician or other licensed health care\nprovider legally authorized to prescribe under title eight of the\neducation law. Such coverage shall be subject to annual deductibles and\ncoinsurance as deemed appropriate by the superintendent. The coverage\nrequired by this subsection shall be identical to, and shall not enhance\nor increase the coverage required as part of essential health benefits\nas defined in subsection (a) of section four thousand three hundred\nsix-h of this article.\n (v) (1) Every contract issued by a medical expense indemnity\ncorporation, hospital service corporation or health service corporation\nwhich provides coverage for inpatient hospital care shall provide such\ncoverage for such period as is determined by the attending physician in\nconsultation with the patient to be medically appropriate after such\ncovered person has undergone a lymph node dissection or a lumpectomy for\nthe treatment of breast cancer or a mastectomy covered by the contract.\nSuch coverage may be subject to annual deductibles and coinsurance as\nmay be deemed appropriate by the superintendent and as are consistent\nwith those established for other benefits within a given policy. Written\nnotice of the availability of such coverage shall be delivered to the\ngroup remitting agent or group contract holder prior to the inception of\nsuch contract and annually thereafter.\n (2) A medical expense indemnity corporation, hospital service\ncorporation or health service corporation which provides coverage under\nthis subsection and any participating entity through which the insurer\noffers health services shall not:\n (A) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the contract or vary the\nterms of the contract for the purpose or with the effect of avoiding\ncompliance with this subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) 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 subsection;\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection; or\n (E) restrict coverage for any portion of a period within a hospital\nlength of stay required under this subsection in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay.\n (3) The prohibitions in paragraph two of this subsection shall be in\naddition to the provisions of sections four thousand three hundred\nseventeen and four thousand three hundred eighteen of this article and\nnothing in this paragraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (w)(1) Every contract issued by a medical expense indemnity\ncorporation or health service corporation which provides medical, major\nmedical, or similar comprehensive-type coverage must provide coverage\nfor a second medical opinion by an appropriate specialist, including but\nnot limited to a specialist affiliated with a spec

ed to suspend, supersede,\namend or otherwise modify such sections.\n (w)(1) Every contract issued by a medical expense indemnity\ncorporation or health service corporation which provides medical, major\nmedical, or similar comprehensive-type coverage must provide coverage\nfor a second medical opinion by an appropriate specialist, including but\nnot limited to a specialist affiliated with a specialty care center for\nthe treatment of cancer, in the event of a positive or negative\ndiagnosis of cancer or a recurrence of cancer or a recommendation of a\ncourse of treatment for cancer, subject to the following:\n (i) In the case of a contract that requires, or provides financial\nincentives for, the covered person to receive covered services from\nhealth care providers participating in a provider network maintained by\nor under contract with the corporation, the contract shall include\ncoverage for a second medical opinion from a non-participating\nspecialist, including but not limited to a specialist affiliated with a\nspecialty care center for the treatment of cancer, when the attending\nphysician provides a written referral to a non-participating specialist,\nat no additional cost to the covered person beyond what such covered\nperson would have paid for services from a participating appropriate\nspecialist. Provided however that nothing herein shall impair the\ncovered person's rights (if any) under the contract to obtain the second\nmedical opinion from a non-participating specialist without a written\nreferral, subject to the payment of additional coinsurance (if any)\nrequired by the contract for services provided by non-participating\nproviders. The corporation shall compensate the non-participating\nspecialist at the usual, customary and reasonable rate, or at a rate\nlisted on a fee schedule filed and approved by the superintendent which\nprovides a comparable level of reimbursement.\n (ii) In the case of a contract that does not provide financial\nincentives for, and does not require, the covered person to receive\ncovered services from health care providers participating in a provider\nnetwork maintained by or under contract with the corporation, the\ncontract shall include coverage for a second medical opinion from a\nspecialist at no additional cost to the covered person beyond what the\ncovered person would have paid for comparable services covered under the\ncontract.\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\ncontract and, where applicable, consistent with the provisions of\nsubparagraphs (i) and (ii) of this paragraph.\n Nothing in this subsection shall eliminate or diminish the\ncorporation's obligation to comply with the provisions of section four\nthousand eight hundred four of this chapter and section forty-four\nhundred three of the public health law where applicable

her benefits within a given\ncontract and, where applicable, consistent with the provisions of\nsubparagraphs (i) and (ii) of this paragraph.\n Nothing in this subsection shall eliminate or diminish the\ncorporation's obligation to comply with the provisions of section four\nthousand eight hundred four of this chapter and section forty-four\nhundred three of the public health law where applicable. Written notice\nof the availability of such coverage shall be delivered to the group\nremitting agent or group contract holder prior to the inception of such\ncontract and annually thereafter.\n (2) A medical expense indemnity corporation or health service\ncorporation which provides coverage under this subsection and any\nparticipating entity through which the insurer offers health services\nshall not:\n (A) deny to a covered person eligibility, or continued eligibility, to\nenroll or to renew coverage under the terms of the contract or vary the\nterms of the contract for the purpose or with the effect of avoiding\ncompliance with this subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) 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 subsection; or\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the effect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection.\n (3) The prohibitions in paragraph two of this subsection shall be in\naddition to the provisions of sections four thousand three hundred\nseventeen and four thousand three hundred eighteen of this article and\nnothing in this paragraph shall be construed to suspend, supersede,\namend or otherwise modify such sections.\n (x) (1) Every contract issued by a medical expense indemnity\ncorporation, hospital service corporation or health service corporation\nwhich provides coverage for surgical or medical care shall provide the\nfollowing coverage for breast or chest wall reconstruction surgery after\na mastectomy or partial mastectomy:\n (A) all stages of reconstruction of the breast or chest wall on which\nthe mastectomy or partial mastectomy has been performed; and\n (B) 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 or\ncoinsurance provisions as may be deemed appropriate by the\nsuperintendent and as are consistent with those established for other\nbenefits within a given policy

ending 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 or\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 group remitting agent or group\ncontract holder prior to the inception of such contract and annually\nthereafter.\n (1-A) Every contract providing coverage as required by paragraph one\nof this subsection shall also provide coverage for the tattooing of the\nnipple-areolar complex pursuant to or as part of such reconstruction if\nsuch tattooing is performed by a licensed physician or other health care\npractitioner licensed, certified, or authorized pursuant to title eight\nof the education law and acting within their scope of practice.\n (2) A medical expense indemnity corporation, hospital service\ncorporation or health service corporation which provides coverage under\nthis subsection and any participating entity through which the insurer\noffers health services shall not:\n (A) 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 subsection;\n (B) provide incentives (monetary or otherwise) to encourage a covered\nperson to accept less than the minimum protections available under this\nsubsection;\n (C) 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 subsection;\n (D) provide incentives (monetary or otherwise) to a health care\npractitioner relating to the services provided pursuant to this\nsubsection intended to induce or have the affect of inducing such\npractitioner to provide care to a covered person in a manner\ninconsistent with this subsection;\n (E) restrict coverage for any portion of a period within a hospital\nlength of stay required under this subsection in a manner which is\ninconsistent with the coverage provided for any preceding portion of\nsuch stay; or\n (F) the prohibitions in this paragraph shall be in addition to the\nprovisions of sections four thousand three hundred seventeen and four\nthousand three hundred eighteen of this article and nothing in this\nparagraph shall be construed to suspend, supersede, amend or otherwise\nmodify such sections.\n * (y) Every contract 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. 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

-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 sb§ (y)'s\n * (y)(1) Every contract issued by a health service corporation or a\nmedical expense indemnity corporation which is a "managed care product"\nas defined in paragraph four of this subsection that includes coverage\nfor physician services in a physician's office, and every "managed care\nproduct" 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. 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 (3) Every contract issued by a health service corporation or a medical\nexpense indemnity corporation which includes coverage for physician\nservices in a physician's office, and every contract which provides\nmajor medical or similar comprehensive-type coverage, other than a\n"managed care product" as defined in paragraph four of this subsection,\nshall provide coverage for chiropractic care, as defined in section six\nthousand five hundred fifty-one of the education law, provided by a\ndoctor of chiropractic licensed pursuant to article one hundred\nthirty-two of the education law, in connection with the detection or\ncorrection by manual or mechanical means of structural imbalance,\ndistortion or subluxation in the human body for the purpose of removing\nnerve interference, and the effects thereof, where such interference is\nthe result of or related to distortion, misalignment or subluxation of\nor in the vertebral column

ticle one hundred\nthirty-two of the education law, in connection with the detection or\ncorrection by manual or mechanical means of structural imbalance,\ndistortion or subluxation in the human body for the purpose of removing\nnerve interference, and the effects thereof, where such interference is\nthe result of or related to distortion, misalignment or subluxation of\nor in the vertebral column. However, chiropractic care and services may\nbe subject to reasonable deductible, co-payment and co-insurance\namounts, reasonable fee or benefit limits, and reasonable utilization\nreview, provided that any such amounts, limits and review: (a) shall\nnot function to direct treatment in a manner discriminative against\nchiropractic care, and (b) individually and collectively shall be no\nmore restrictive than those applicable under the same contract to care\nor services provided by other health professionals in the diagnosis,\ntreatment and management of the same or similar conditions, injuries,\ncomplaints, disorders or ailments even if differing nomenclature is used\nto describe the condition, injury, complaint, disorder or ailment.\nNothing herein contained shall be construed as impeding or preventing\neither the provision or coverage of chiropractic care and services by\nduly licensed doctors of chiropractic, within the lawful scope of\nchiropractic practice, in hospital facilities on a staff or employee\nbasis.\n (4) For purposes of this subsection, a "managed care product" shall\nmean a contract which requires that medical or other health care\nservices covered under the contract, other than emergency care services,\nbe provided 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 corporation'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\ncorporation's managed care provider network, in order for the insured to\nbe entitled to the maximum reimbursement under the contract.\n (5) The coverage required by this subsection shall not be abridged by\nany regulation promulgated by the superintendent.\n * NB There are 2 sb§ (y)'s\n (z) No contract issued by a medical expense indemnity corporation, a\nhospital service corporation or a health service corporation shall\nexclude coverage of a health care service, as defined in paragraph two\nof subsection (e) of section four thousand nine hundred of this chapter,\nrendered or proposed to be rendered to an insured on the basis that such\nservice is experimental or investigational, is rendered as part of a\nclinical trial as defined in subsection (b-2) of section forty-nine\nhundred of this chapter, or a prescribed pharmaceutical product\nreferenced in subparagraph (B) of paragraph two of subsection (e) of\nsection forty-nine hundred of this chapter provided that coverage of the\npatient costs 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

on forty-nine hundred of this chapter provided that coverage of the\npatient costs 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 subsection\nshall be provided subject to the terms and conditions generally\napplicable to other benefits provided under the policy.\n (z-1) (1) Every policy delivered or issued for delivery in this state\nwhich provides medical coverage that includes coverage for physician\nservices in a physician's office and every policy which provides major\nmedical or similar comprehensive-type coverage shall provide, upon the\nprescription of a health care provider legally authorized to prescribe\nunder title eight of the education law, the following coverage for\ndiagnostic screening for prostatic cancer:\n (A) standard diagnostic testing including, but not limited to, a\ndigital rectal examination and a prostate-specific antigen test at any\nage for men having a prior history of prostate cancer; and\n (B) an annual standard diagnostic examination including, but not\nlimited to, a digital rectal examination and a prostate-specific antigen\ntest for men age fifty and over who are asymptomatic and for men age\nforty and over with a family history of prostate cancer or other\nprostate cancer risk factors.\n (2) Such coverage shall not be subject to annual deductibles or\ncoinsurance.\n (aa)(1) Every contract issued by a hospital service company or health\nservice corporation which provides major medical or similar\ncomprehensive-type coverage shall include coverage for prehospital\nemergency medical services for the treatment of an emergency condition\nwhen such services are provided by an ambulance service issued a\ncertificate to operate pursuant to section three thousand five of the\npublic health law.\n (2) Payment by an insurer pursuant to this section shall be payment in\nfull for the services provided. An ambulance service 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 subsection, except for the collection of copayments, coinsurance or\ndeductibles for which the insured is responsible for under the terms of\nthe policy.\n (3) An insurer shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the insurer and\nthe provider of such services. In the absence of agreed upon rates, an\ninsurer shall pay for such services at the usual and customary charge,\nwhich shall not be excessive or unreasonable

for which the insured is responsible for under the terms of\nthe policy.\n (3) An insurer shall provide reimbursement for those services\nprescribed by this section at rates negotiated between the insurer and\nthe provider of such services. In the absence of agreed upon rates, an\ninsurer shall pay for such services at the usual and customary charge,\nwhich shall not be excessive or unreasonable. The insurer shall send\nsuch payments directly to the provider of such ambulance services, if\nthe ambulance service has on file an executed assignment of benefits\nform with the claim.\n (4) The provisions of this subsection shall have no application to\ntransfers of patients between hospitals or health care facilities by an\nambulance service as described in paragraph one of this subsection\nunless such services are covered under the policy.\n (5) As used in this subsection:\n (A) "Prehospital emergency medical services" means the prompt\nevaluation and treatment of an emergency medical condition, and/or\nnon-air-borne transportation of the patient to a hospital; provided\nhowever, where the patient utilizes non-air-borne emergency\ntransportation pursuant to this subsection, reimbursement shall be based\non whether a prudent layperson, possessing an average knowledge of\nmedicine and health, could reasonably expect the absence of such\ntransportation to result in (i) placing the health of the person\nafflicted with such condition in serious jeopardy, or in the case of a\nbehavioral condition placing the health of such person or others in\nserious jeopardy; (ii) serious impairment to such person's bodily\nfunctions; (iii) serious dysfunction of any bodily organ or part of such\nperson; (iv) serious disfigurement of such person; or (v) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nSocial Security Act.\n (B) "Emergency condition" means a medical or behavioral condition that\nmanifests itself by acute symptoms of sufficient severity, including\nsevere pain, such that a prudent layperson, possessing an average\nknowledge of medicine and health, could reasonably expect the absence of\nimmediate medical attention to result in (i) placing the health of the\nperson afflicted with such condition in serious jeopardy, or in the case\nof a behavioral condition, placing the health of such person or others\nin serious jeopardy; (ii) serious impairment to such person's bodily\nfunctions; (iii) serious dysfunction of any bodily organ or part of such\nperson; (iv) serious disfigurement of such person; or (v) a condition\ndescribed in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the\nSocial Security Act.\n (bb) A health service corporation or a medical service expense\nindemnity corporation that provides major medical or similar\ncomprehensive-type coverage shall provide such coverage for bone mineral\ndensity measurements or tests, and if such contract otherwise includes\ncoverage for prescription drugs, drugs and devices approved by the\nfederal food and drug administration or generic equivalents as approved\nsubstitutes

rporation or a medical service expense\nindemnity corporation that provides major medical or similar\ncomprehensive-type coverage shall provide such coverage for bone mineral\ndensity measurements or tests, and if such contract otherwise includes\ncoverage for prescription drugs, drugs and devices approved by the\nfederal food and drug administration or generic equivalents as approved\nsubstitutes. In determining appropriate coverage provided by paragraphs\none, two and three of this subsection, 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 (1) For purposes of paragraphs two and three of this subsection, bone\nmineral density measurements or tests, drugs and devices shall include\nthose covered under the criteria of the federal Medicare program as well\nas those in accordance with the criteria of the national institutes of\nhealth, including, as consistent with such criteria, dual-energy x-ray\nabsorptiometry.\n (2) For purposes of paragraphs one and three of this subsection, bone\nmineral density measurements or tests, drugs and devices shall be\ncovered for individuals meeting the criteria for coverage, consistent\nwith the criteria under the federal Medicare program or the criteria of\nthe national institutes of health; provided that, to the extent\nconsistent with such criteria, individuals qualifying for coverage\nshall, 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 (3) Such coverage required pursuant to paragraph one or two of this\nsubsection may be subject to annual deductibles and coinsurance as may\nbe deemed appropriate by the superintendent and as are consistent with\nthose established for other benefits within a given policy.\n (4) In addition to paragraph one, two or three of this subsection,\nevery contract that provides hospital, surgical or medical care\ncoverage, except for a grandfathered health plan under paragraph five of\nthis subsection, shall provide coverage for the following items or\nservices for bone mineral density, and such coverage shall not be\nsubject to annual deductibles or coinsurance:\n (A) 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 (B) with respect to women, such additional preventive care and\nscreenings for bone mineral density not described in subparagraph (A) of\nthis paragraph and as provided for in comprehensive guidelines supported\nby the health resources and services administration.\n (5) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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

nsive guidelines supported\nby the health resources and services administration.\n (5) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March 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 (cc) (1) Every contract that provides medical, major medical, or\nsimilar comprehensive type coverage that is issued, amended, renewed,

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